Travis Donoho

Physical Examination: Abdomen Case 1.1: Elio Martinez

Indications: Abdominal pain, indigestion, nausea, vomiting, diarrhea,

constipation, urinary or fecal incontinence, jaundice, dysuria, urinary frequency abnormality, hematuria There are four main components to an abdominal physical exam: 1. 2. 3. 4. Observation Auscultation Percussion Palpation

(These are also the component of cardiac and pulmonary exams, and often chest problems can be perceived by the patient as abdominal problems, so it is a good idea to also do a physical exam of the chest while doing the abdominal exam.

1. OBSERVATION

http://www.nlm.nih.gov/medlineplus/ency/imagepages/19578.htm

The abdomen is divided into four quadrants: The right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ), and left lower quadrant (LLQ). When examining each quadrant throughout the physical exam, be aware of what organs reside in that quadrant so that you can evaluate normal versus abnormal presentation of the internal anatomy. Alternately, some clinicians choose to imagine the abdomen divided into nine regions. Choose one and use it consistently.

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Physical Examination: Abdomen Case 1.1: Elio Martinez

http://ssmhealth.adam.com/content.aspx?pid=13&gid=100049

The exam should ideally be conducted in a warm, quiet, well-lighted room. The provider traditionally stands on the right side of the supine patient. The patient should have an empty bladder. The patient's head on a pillow and arms on the table to the patients sides will help keep the abdomen relaxed for examination. Bending the knees can also help relax abdominal muscles. Uncover the patient's entire abdomen, but take care to keep the private areas covered as much as possible. EVALUATE: Appearance o Is the abdomen flat, concave, or distended? o If it is enlarged, is the enlargement symmetrical? o Stand at the end of the patient's bed, looking toward the head to evaluate symmetry. o If there are protrusions, there could be organomegaly. o If the protrusion becomes more pronounced when the patient bears down in the Valsalva maneuver, there could be a ventral hernia. Those are often a result of abdominal weakening due to a previous surgery. o If there is a generalized distension, it is usually the result of air, fluid, or fat. Distinguishing between them is difficult with observation alone. Presence of surgical scars, striae, hernias, vascular changes, lesions, rashes, or other abnormalities Patient's movement or lack of movement o Appendicitis and other peritonitis hurts worse with movement, so the patient will often lie perfectly still as much as possible. o A patient with kidney stones cannot get comfortable in any position and will often actively keep searching for a position providing relief.

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Physical Examination: Abdomen Case 1.1: Elio Martinez

Also look for externally visible movement within the abdomen, of peristalsis or pulsation.

2. AUSCULTATION
Auscultation, or listening for internal sounds, is performed prior to percussion or palpation in an abdominal exam to avoid disturbing the activity of the bowels and compromising the accuracy of the auscultatory examination. Rub the stethoscope against your shirt briefly to warm it, then place the diaphragm anywhere on the abdomen to listen for bowel sounds. The exact location is not important, because the abdominal cavity has no actual walls and sound travels nonspecifically throughout. LISTEN FOR: Are there bowel sounds? Are they frequent or infrequent? What is the nature and quality of the sound? Bowel sounds are caused by peristalsis, the movement of food and liquid through the bowels. Normally, you will hear a sound every 2-5 seconds. A quiet bowel may suggest an inflammation of the serosa covering the organs. Peritonitis is an example. A hyperactive bowel may suggest an inflammation of the mucosa inside the bowels, as with an infection causing diarrhea. Frequent bowel sounds ("rushes") followed by a weaker sound ("tinkles") and then silence can suggest an obstruction. Following a trauma, such as an injury or a surgery, several days may pass before any bowel sounds can be heard. The return of bowel sounds is a good sign of recovery. After listening for bowel sounds, it may be useful to also listen for renal artery bruit, a high-pitched murmur, caused by blood passing through an atherosclerotic (narrowed) vessel. Place the diaphragm a few centimeters above the belly button, along the edge of the rectus muscles and press firmly, because the renal arteries are retroperitoneal. Indications for this part of the exam include renal insufficiency, hard-to-manage hypertension, or a known vascular disease. Atherosclerosis of the proximal iliac arteries will also yield an audible bruit. The aorta itself will not produce any useful diagnostic sound.

3. PERCUSSION
You are looking for two basic sounds: Tympanic (drum-like) sounds over air-filled structures

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Physical Examination: Abdomen Case 1.1: Elio Martinez

Dull sounds over solid structures ( the liver or the spleen) or fluid (in the case of ascites)

Rub your hands together to warm them. Then place the palmar surface of the middle finger of the left hand firmly against the abdomen, and use a floppy wrist action to strike the distal interphalangeal joint 2 or 3 times with the tip of the right middle finger. (Note if percussion causes pain, which may point to an inflammation.) PERCUSSION
OF ORGANS

The stomach has an air bubble in it that should produce a very tympanic sound over the lower left rib cage, near the sternum. The spleen is small, located extremely laterally, and entirely obscured by the ribs. The ability to percuss a dull tone in the LUQ can suggest splenomegaly. We can get a pretty good idea of the size of the liver with percussion. Follow an imaginary line from the midshaft of the patient's right clavicle down to just below the right breast, in an area overlying the base of the right lung. Percuss there, expecting a resonant note indicative of air-filled lungs. Move down a few centimeters and repeat. Continue this process until you hit a dull note. This will be the superior aspect of the liver. Continue moving down until the sound changes again. This will be the inferior aspect of the liver. The total span between the two points is usually 6-12 cm. This is a difficult process on a large patient. AIR-FLUID
LEVELS

Percussion can reliably distinguish between fluid and gas etiology of a distended abdomen, owing to the fact that air will always float on fluid. With the patient supine, begin at the belly button and percuss laterally, continuing posteriorly until you reach the table. A change from tympanic to dull sounds can suggest ascites, excess fluid in the abdominal cavity. Mark where the change occurs bilaterally. Place the patient in a left lateral decubitus position and percuss again, still at the level of the belly button, moving from the point closest to the ceiling toward the point closest to the table. If ascites is present, the line demonstrating air fluid level will have shifted. There has to be a fairly large amount of fluid for this method to work.

4. PALPATION
Warm your hands by rubbing them together. Use the pads and tips of the index, middle and ring fingers of the right hand as examining surfaces to palpate the liver, spleen and deeper structures. Apply slow, steady pressure to examine each quadrant, keeping in mind what structures reside in each quadrant. You will do this lightly and then deeply, paying attention the patient's face for expression of pain or discomfort.

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Physical Examination: Abdomen Case 1.1: Elio Martinez

Start in the RUQ of the supine patient, about 10 cm below the rib margin in the midclavicular line, in an area that you are relatively sure is below the liver. Gently push posteriorly and superiorly, roughly parallel to the rectus muscle. Repeat this, moving the fingers toward the head until the edge of the liver is palpated. In an obese patient, it may be beneficial to use the "hook" technique to feel the edge of the liver. Stand by the patient's chest, hook your fingers firmly under the right lower rib margin and tell the patient to take a deep breath. To evaluate the kidneys, palpate the patient's back, at the inferior, lateral margin of the ribs while applying an opposing force on the patient's abdomen with your left hand. If the kidney is enlarged or edemic, it may be palpable. If it hurts, there may be an inflammation. Pounding with the fist on the patient's back at the articulation of the lower ribs and vertebra can elicit costovertebral tenderness (CVAT), which is also an indicator of possible inflammation or renal disease. To evaluate the LUQ, particularly the spleen, begin palpating near the belly button and work your way slowly toward the left ribs, superficially and then more deeply. Then start again laterally, about 10 cm below the lower rib margin and work your way back up to the ribs. The spleen is likely to "hide", shifting away from your fingers. These two angles are the most likely approaches for successful palpation and more importantly the most common directions of spleen enlargement. The edge, when palpable, will be soft, rounded and superficial. It can be helpful to repeat the LUQ exam with the patient lying in right lateral decubitus position so that gravity will aid in making the spleen more palpable. Examine the LLQ and RLQ, superficially and then more deeply. The LLQ may yield a stool-filled sigmoid colon and the RLQ a stool-filled cecum. A full bladder can be palpable above the pelvic brim, however it is preferred to conduct the abdominal exam with the patient's bladder empty. A pregnant uterus can also sometimes be palpated. Tenderness during palpation of the RLQ is called Rovling's sign and can suggest appendicitis. Two more ways to evaluate for appendicitis include the psoas sign and the obturator sign. Place a hand above the patient's right knee and tell the patient to flex the right hip. If pain increases, this is a positive psoas sign. Flex the patient's right knee and raise the leg, rotating it internally at the hip. If pain increases, this is a positive obturator sign. The pulsating abdominal aorta can sometimes be felt by pushing a hand deeply into the abdomen above the belly button. It is difficult to feel because it is retroperitoneal, but if you can feel it, also attempt to estimate its size by putting the palms of the hands on either side of the aorta and pushing down to feel for width of it, which should be about 3 cm or less. Also use palpation to follow up on any questions that arose during the preceding components of the physical exam, such as a visual protrusion or an unexpected tympanic percussion.

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Physical Examination: Abdomen Case 1.1: Elio Martinez

Goldberg, Charlie, M.D., UCSD School of Medicine and VA Medical Center, "A Practical Guide to Clinical Medicine," University of California - San Diego. http://meded.ucsd.edu/clinicalmed/abdomen.htm. Accessed on 7 June 2011. Rathe, Richard, M.D., "Examination of the Abdomen," University of Florida. 2000. http://medinfo.ufl.edu/year1/bcs/clist/abdomen.html Accessed on 7 June 2011. Seidel, Henry M., et al. Mosby's Guide to Physical Examination. 7th edition. St. Louis, Mo. : Mosby Elsevier, 2011.