Abdominal Examination UMY

Abdominal Examination
General principles of exam
Abdominal Examination
The History and Physical in
Perspective
70% of diagnoses can be made based on
history alone.
90% of diagnoses can be made based on
history and physical exam.
Expensive tests often confirm what is
found during the history and physical.
Equipment for physical examination
Required Optional
Stethoscope Gloves
Tongue blades Gauze pads
Penlight Lubricant gel
Tape measure Nasal speculum
Sphygmomanometer Turning fork: 128 Hz,512Hz
Reflex hammer Pocket visual acuity
Safety pins card
Oto-ophthalmoscope
Important aspects of physical
examination----physician
Elegant appearance
Decent manner
Kind attitude
Highly responsibility
Good medical
morals
examination---physician
Wash your hands,
preferably while the
patient is watching
Washing with soap

and water is an
effective way to
reduce the
transmission of
disease
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
examination
The examiner should
continue speaking to
the patient
Showing care to his

disease and answer to
patients questions
It can not only release

patients nerviness, but
also help to establish
the good physician-
patient relationship
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
Good light
Relaxed
patient
Full exposure
of abdomen
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
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
Use warm hand,
warm stethoscope,
and have short finger
nails
Approach the patient
slowly and
deliberately
explaining what you
will be doing
Stand right side of the

bed
Exam with right hand
Head just a little
elevated
Ask the patient to
keep the mouth
partially open and
breathe gently
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
If the patient is ticklish
or frightened
Initially use the
patients hand under
yours as you palpate
When patient calms
then use your hands
to palpate.
Watch the patients
face for discomfort.
Think
Anatomically
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
Inspection
Abdominal examination
Appearance of the abdomen
Is Aortic pulsation?
Is it flat or Scaphoid
(Normally)?
Distended?
If enlarged, does this
appear symmetric?
With bulging or
moving?
Symmetrical in shape
slightly full but not distended in older age

Scaphoid or flat in young group due to poor muscle tone or in
patients of normal weight subjects who are mildly overweight
Appreciation of abdominal contours
Standing at the foot of

the table and looking up
towards the patient's
head.
Lower yourself until the
anterior abdominal
wall and ask the patient
to breathe normally while
you are doing so.
Global
abdominal
enlargement is
usually caused
by air, fluid, or
fat.
Localized
enlargement
probably distend
GB space
occupying lesion,
hepatomegaly.
An aortic aneurysm
Palpable mass
Patient feeling of
pulsation
On rare occasions, a
lump can be visible.
An aortic aneurysm
1 in 10 men over 65
may have some
enlargement of the
abdominal aorta.
About 1 in 100 will
have a large
aneurysm requiring
surgery.
(Skin)
Abnormal venous
patterns
Abnormal
discoloration
Umbilicus is sunken
Striae
Stretch marks are a
light silver hue.
Pregnancy and obese
individuals
Cushings syndrome
(more purple or pink).
(Skin)
Tattoos
Scars can be drawn
on schematic
diagrams of the
abdomen (a picture is
worth a thousand
words).
Cullens sign
Ecchymosis
periumbilically.
(intraperitoneal
hemorrhage
ruptured ectopic
pregnancy,
hemorrhagic
pancreatitis..)
Grey-Turners sign
Ecchymosis of
flanks.
(retroperitoneal
hemorrhage
such as
hemorrhagic
pancreatitis)
SVC = superior vena cava IVC = inferior vena cava
Upward flow direction indicates IVC obstruction
Outward flow pattern from umbilicus in all directions ? Portal HTN
Evaluate venous return states
Place index finger

side by side over a
vein and press
laterally, milking vein.
Release one finger
and time refill, repeat
with other finger.
Venous return is in
direction of faster
filling.
Areas which
become more
pronounced when
the patient
valsalvas are
often associated
with ventral
hernias
Visible Pulsations
More conspicuous in the In those with an aortic
thin than in the fat aneurysm and tortuous
Greater in the old than in aorta
the young. In those who have a
Increased in mass joining the aorta to
thyrotoxicosis, the anterior abdominal
hypertension, or aortic wall.
regurgitation)
Visible gastric Peristalsis Visible intestinal Peristalsis
Gastric peristalsis is Intestinal peristalsis in

commonly seen in partial and chronic
neonates with intestinal obstruction
congenital Colonic obstruction is
hypertrophic pyloric usually not manifest
stenosis as visible peristalsis
Patient's movement
Patients with kidney

stones will frequently
writhe on the
examination table,
unable to find a
comfortable
position
Patient's movement
Patients with
peritonitis prefer to lie
very still as any
motion causes further
peritoneal irritation
and pain.
Auscultation
Auscultation
Bowel sounds
Vascular sounds (bruits)
Friction Rubs
Auscultation for bowel sounds
It is performed before percussion or

palpation
Normal sounds are
due to peristaltic
activity.
Peristalsis: A
pregressice wavelike
movement that occurs
involuntarily in hollow
tubes of the body.
Compared to the
cardiac and
pulmonary exams,
auscultation of the
abdomen has a
relatively minor role.
Bowel sounds lend

supporting
information to other
findings but are not
pathognomonic
for any particular
process.
Auscultation
1.Diaphragm of
stethoscope
used
2.Skin
depressed to
approximately 1
cm
Auscultation
3.Listening in one
spot is usually
sufficient
4.Listening for 15-20
or 30-60 seconds
5.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.
Inflammation of the
intestinal mucosa
will cause
hyperactive bowel
sounds.
Processes which
lead to intestinal
obstruction initially
cause frequent
bowel sounds,
referred to as
"rushes."
Auscultation for bowel
sounds
Processes which lead
to intestinal
obstruction initially
cause frequent bowel
sounds, referred to as
"rushes."
Rushes" means
as the intestines
trying to force
their contents
through a tight
opening.
sounds
Rushes" is followed
by decreased sound,
called "tinkles," and
then silence.
sounds
After silence the
appearance of bowel
sounds marks the
return of intestinal
sounds activity, an
important phase of
the patient's recovery.
Splash Sign
Splashing sound
indicative of air or
fluid in body cavity
with shaking
individual: normal in s
stomach.
Bowel sounds,
then, must be
interpreted within
the context of the
particular clinical
situation.
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)
(bruits)
Presence of a bruit
on the renal artery
would lend
supporting
evidence for the
existence of renal
artery stenosis.
(bruits)
When listening for
bruits, you will need
to press down quite
firmly as the renal
arteries are
retroperitoneal
structures.
Venous Hum (rare)
Epigastric/umbilical
area.
Soft humming noises
in systolic/diastolic
component.
Indicates collateral
between portal and
venous systems as in
hepatic cirrhosis.
Rubs Rubs-Rubs
Liver
Spleen
Cardiac
Pulmonary
Friction rubs (rare)
Right and left upper

quandrants
Grating sound with
respiratory movement
Indicates
inflammation of the
capsule of the liver or
spleen (infection or
infarction).
Percussion
Percussion
Technique
Liver
Spleen
Percussion (technique)
DIP joint of third

finger (pleximeter)
pressed firmly on the
abdomen remainder
of hand not touching
the abdomen
Striking hand
should move
only at the wrist,
with only little
more than force
of gravity
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
The two solid organs are
percussable in the normal patient
Liver: will be entirely
covered by the ribs.
Occasionally, an edge
may protrude 1-2
centimeter below the
costal margin.
Spleen: The spleen is
smaller and is entirely
protected by the ribs.
To determine the size of the liver
Measure the liver
span by percussing
hepatic dullness from
above (lung) and
below (bowel). A
normal liver span is 6
to 12 cm in the
midclavicular line.
Start just below the
right breast in a line
with the middle of
the clavicle.
Percussion in this
area should
produce a relatively
resonant note.
Move your hand
down a few
centimeters than
you will be over
the liver, which
will produce a
duller sounding
tone.
Continue
downward until
the sound
changes once
again. At this
point, you will
have reached 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
To determine the size of the
liver
The resonant tone produced by
percussion over the anterior chest
wall will be somewhat less drum like
then that generated over the
intestines. While they are both
caused by tapping over air filled
structures, the ribs and pectoralis
muscle tend to dampen the sound.
Examination of Spleen
(Percussion)
Percussion at Castells Spot
Castells Spot identified
Left anterior axillary line identified
Left lower costal margin identified
Percussion at Castells Spot while patient
inhales and exhales deeply
Dull tone indicates

possible splenomegaly
Spleen percussion
Enlarged spleen
produce a dull
tone, in the left
upper quadrant
percussion but
should then be
verified by
palpation.
Palpation
Abdominal Palpation
Technique Spleen tip

Light Kidneys
Deep Aorta
Liver edge 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
Abdominal palpation
Use pads of three
fingers of one hand
and a light, gentle,
dipping maneuver to
examine abdomen
Palpation (light)
Any areas of pain or
tenderness are
reserved for
evaluation at the end
of the exam
Light Palpation
Mostly looking for
areas of tenderness
Tenderness is a
physical exam finding
a reflex occurs
(muscle splinting,
wide eyes, moaning,
teeth gritting).
Palpation
Light palpation assesses
Muscle tone
Cutaneous
hypersensitivity
(suggests peritoneal
irritation)
Palpation
Light palpation assesses
Presence of
superficial
(intramural) masses is
more prominent if
patient raises their
head ,Intra-abdominal
mass is less
prominent if patient
raises their head
Deep Palpation
Palpation (deep)
Entire palm
Either one- or
two handed
technique is
acceptable
Deep Palpation
Use palmar surface of
fingers of one hand
(greatest number of
fingers) and a deep,
firm, gentle maneuver
to examine abdomen
Palpation
Palpate deeply with

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
Palpation (deep)
Push as deeply as
patient will allow
without significant
discomfort
Normal structure that may be
palpable
Sigmoid colon Distended bladder
Liver Gravid and non-
Kidney gravid uterus
Abdominal aorta Xyphoid process
Iliac artery spleen
Abdominal mass
Intra abdominal
masses or
enlargements of the
liver, gallbladder or
spleen
Abdominal wall mass
Intra abdominal masses or enlargements of
the liver, gallbladder or spleen
They will shift down
with inspiration and
back with expiration.
(not true of masses
within the abdominal
wall or retroperitoneal
structures).
Abdominal wall mass
It will become more
evident and palpable
when patient flexes
neck as this contracts
rectus muscles.
Paraumbilical node
Abdominal pain and
Tenderness
Type of abdominal pain
Visceral pain Somatic pain

Visceral pain
This is pain that
arises 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
Tenderness
If there is tenderness
determine the point of
maximum tenderness
and its distribution
Abdominal muscle spasm
Voluntary guarding Involuntary guarding
Tensing abdominal Muscular spasm or
muscles due to rigidity due to
patient anxiety, peritoneal
ticklishness, or inflammation
toprevent palpation to May be localized
a painful area (early appendicitis )or
diffuse (perforated
bowel)
Board-like rigidity
If abdominal wall is
palpated as obviously
tense, even as rigid
as a board, board-like
rigidity is so called. Is
caused by the spasm
of abdominal muscle
due to peritoneal
irritation.
Differential diagnosis of abdominal
pain
Spine pain
Abdominal wall
pain( differentiated by
having the patient
tense his abdominal
muscles, by forcefully
elevating his head
while keeping his
shoulders flat on the
table)
Liver palpation
Liver palpation
(Standard Method)
Start in the RUQ,10
centimeters below the
rib margin in the mid-
clavicular 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
Liver palpation
Another method of
palpating the liver
uses the radial border
of the index finger. In
this method the
anterior hand is
placed flat on the
anterior abdominal
wall with fingers
parallel to the costal
margin
Alternate Method Liver palpation
Is useful when the

patient is obese or
when the examiner
is small compared
to the patient.
Alternate Method Liver palpation
Stand by the patient's

chest.
"Hook" your fingers
just below the costal
margin and press
firmly.
Hepatomegaly
More than 1cm below
the costal margin
An exception is a
congenitally large
right lobe of the liver
Severe, chronic
emphysema
Pulsation transmitted from aorta Tricuspid valve insufficiency
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.
Ballotable sign
Spleen palpation
Spleen palpation
Seldom palpable in
normal adults.
Causes include
COPD, and deep
inspiratory descent of
the diaphragm.
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.
Examination of Spleen
(Palpation)
Deep technique used

Starting point is RLQ,
proceeding to LUQ
Kidney palpation
Kidney palpation
Place left hand
posteriorly just below
the right 12th rib. Lift
upwards.
Palpate deeply with
right hand on anterior
abdominal wall.
Examination of Kidney
Patient take a deep
breath.
Feel lower pole of
kidney and try to
capture it between
your hands.
Examination of Kidney
Right kidney may be felt to slip between hands

during exhalation
Palpation of the Aorta
Examination of Aorta
Flat palm placed

over the the
epigastrium to
locate pulse
Press down deeply in
the midline above the
umbilicus.
The aortic pulsation is
easily felt on most
individuals.
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.
Lateral width of pulsation is determined by

space between index fingers
Special exam
Special exam
Murphys Sign Re bound
McBurneys Tenderness
Point Costovertebral
Rovsings Sign tenderness
Psoas Sign Shifting
Obturator Dullness
Sign
Fluid wave
Murphys Sign (acute cholecystitis)
Examiners 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
McBurneys 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.
McBurneys Point (Common Causes)
Appendicitis
Incarcerated or
strangulated hernia
Ovarian torsion (twisted
Fallopian tube)
Pelvic inflammatory
disease
Abdominal abscess
Hepatitis
Diverticular disease
Meckel''s diverticulum
Rovsings Sign
Patient will
experience right lower
quadrant pain (in
region of McBurneys
Point) when left lower
quadrant is palpated.
Non-Classical Appendicitis
Iliopsoas Sign
Obturator Sign
Iliopsoas Sign
Patient can lay on side and extend leg at the hip

or have patient lay on back and try to flex hip
against the resistance of examiners hand on
thigh. If patient has an inflamed retrocecal
appendix, this will produce 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]
Cost vertebral 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.
Warn the patient Patient sit up on the exam table
Shifting Dullness
(For peritoneal fluid)
Percuss from anterior

abdomen laterally to
outline areas of
dullness noted
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
Shifting Dullness
Fluid wave

Abdominal Examination UMY

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Abdominal Examination UMY

Caricato da

Copyright:

Formati disponibili

Abdominal Examination

General principles of exam

Washing with soap

Exposing only the

Showing care to his

It can not only release

Stand right side of the

Take a spare bed

slightly full but not distended in older age

Standing at the foot of

Place index finger

Gastric peristalsis is Intestinal peristalsis in

Patients with kidney

It is performed before percussion or

Bowel sounds lend

Right and left upper

DIP joint of third

Dull sounds that

Dull tone indicates

Technique Spleen tip

Palpate deeply with

Visceral pain Somatic pain

Ask the patient to

Is useful when the

Stand by the patient's

Support lower left rib

Deep technique used

Right kidney may be felt to slip between hands

Flat palm placed

Hands then oriented

A well defined, pulsatile mass, greater than

Lateral width of pulsation is determined by

Patient can lay on side and extend leg at the hip

Internally rotate right leg at the hip with the knee

Warn the patient what

Percuss from anterior

Potrebbero piacerti anche