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Kamis, 14 Februari 2013



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.



Signs and symptoms
Reports of difficulty swallowing Difficulty controlling food or saliva in mouth Facial droop Dementia, frailty, confusion Inability to sit upright

Gastroesophageal Reflux Disease

Signs and symptoms
Heartburn Indigestion Belching:(also known as burping, ructus, or eructation)
involves the release of gas from the digestive tract (mainly esophagus and stomach) through the mouth.

Hiccups Regurgitation of gastric contents Voice hoarseness


Liver and Biliary Disorders

Signs and symptoms
Older adults often present with vague, ambiguous symptoms Fatigue Weight loss Anorexia Malaise


Think Anatomically

Think Anatomically
When looking, listening, feeling and percussing imagine what organs live in the area that you are examining.

Quadrants & Regions of the abdomen

MSP: mid-sagittal plane TUP: transumblical plane (L4/5)

RLL: right lateral plane LLL : left lateral plane TPP: transpyloric plane (L 1) TTP: transtubercular plane (L 5)

Regions of the abdomen

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

General Considerations
1. 2. 3. 4. 5. 6. 7. The patient should have an empty bladder. The patient should be lying supine on the exam table and appropriately draped. The examination room must be quiet to perform adequate auscultation and percussion. Watch the patient's face for signs of discomfort during the examination. Use the appropriate terminology to locate your findings Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the chest when evaluating an abdominal complaint. Consider the inguinal/rectal examination in males. Consider the pelvic/rectal examination in females.

EXAM SECTIONS 1. Inspection 2. Auscultation 3. Percussion 4. Palpation

Physicians locate findings in the abdomen in one of four quadrants or one of nine regions. The four quadrants are: right upper (RUQ), right lower (RLQ), left upper (LUQ) and left lower (LLQ). THE NINE REGIONS epigastric, umbilical, hypogastric/suprapubic, right hypochondriac, left hypochondriac, right lumbar, left lumbar, right inguinal and left inguinal.



The schematic below is a reminder of what organs are likely to produce findings in each region. For example:
Right hypochondriac (RUQ) : liver and gall bladder left hypochondriac (LUQ) : the spleen and stomach epigastric : the pancreas, stomach and common bile duct umbilical : the small intestine lumbar : the kidneys iliac regions : the ovaries left iliac/LLQ : the sigmoid colon right iliac or lumbar (RLQ): the cecum and appendix suprapubic : the bladder and uterus


Scars : Jaringan parut Striae (stretch marks) : tanda peregangan ibu hamil Colors : - Bluish color at the umbilicus is Cullen's sign a sign
of bleeding in the peritoneum. - Bruises on the flanks are Grey Turner's sign (retroperitoneal bleeding - e.g. from inflamed pancreas)

Jaundice : warna kuning pada kulit Prominent veins : may be due to portal vein obstruction or inferior vena cava obstruction

Distension of the lower abdomen only can be caused by pregnancy, full bladder, ovarian tumor, or uterine fibroids (common benign growths) Diffuse abdominal distension can be caused by any of the 6 Fs:
Fat (obesity) Fluid (ascites - peritoneal fluid - or obstructed viscera filled with fluid) Flatus (air) - e.g. from air swallowing or intestinal obstruction Feces (constipation Fetus (pregnancy) Fatal cancer.

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

Scaphoid or flat in young patients of normal weight

slightly full but not distended in older age group due to poor muscle tone or in 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.

Appearance of the abdomen

Global abdominal enlargement is usually caused by air, fluid, or fat.

Appearance of the abdomen

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.

Appearance of the abdomen (Skin)

Abnormal venous patterns Abnormal

discoloration Umbilicus is sunken

Stretch marks are a light silver hue. Pregnancy and obese individuals Cushings syndrome (more purple or pink).

Appearance of the abdomen (Skin)

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)

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.

Appearance of the abdomen

Areas which become more pronounced when the patient valsalvas are often associated with ventral


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


Appearance of the abdomen Patient's movement

Patients with peritonitis prefer to lie very still as any motion causes further peritoneal irritation and pain.

Use the diaphragm of your stethoscope to listen to gut sounds Normal gut sounds are gurgling, 5 to 35 per minute Borborygmi are loud, easily audible sounds. They are normal, too. High pitched , tinkling (raindrops in a barrel) sounds are a sign of early intestinal obstruction Decreased sounds: (none for a minute) are a sign of decreased gut activity. Gut sounds may be markedly decreased after abdominal surgery; abdominal infection (peritonitis) or injury. Absent Sounds : (no sounds for 5 minutes) are a bad sign. They can be caused by longer-lasting intestinal obstruction, intestinal perforation or intestinal (mesenteric) ischemia or infarction

Active bowel sounds 5-30/min Hypoactive 4/min or less Hyperactive 30 or more /min Bruits o A. Aorta o B. Renal o C. Iliac Friction rub

Auscultation for bowel sounds

It is performed before percussion or palpation

Auscultation for bowel sounds

Normal sounds are due to peristaltic

Peristalsis: A pregressice wavelike movement that occurs involuntarily in hollow tubes of the body.

Auscultation for bowel sounds

Compared to the cardiac and pulmonary exams, auscultation of the abdomen has a relatively minor role.

Auscultation for bowel sounds

Bowel sounds lend supporting information to other findings but are not

for any particular process.

1.Diaphragm of stethoscope used 2.Skin depressed to approximately 1 cm

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.

Auscultation for bowel sounds

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

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.

Auscultation for bowel 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.

Auscultation for bowel sounds

Bowel sounds, then, must be interpreted within the context of the particular clinical situation.

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.

Auscultation for vascular sounds (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).

What it finds: liver size (kind of), spleen, fluid. Percussing the body gives one of three notes: Tympany is found in most of the abdomen, caused by air in the gut. It has a higher pitch than the lung. Resonance is found in normal lung. It is lower pitched and hollow. Dullness is a flat sound, without echoes. The liver and spleen, and fluid in the peritoneum (ascites: ah-SY-teez), give a dull note.

A. Liver Span Percuss downward from the chest in the right midclavicular line until you detect the top edge of liver dullness. Percuss upward from the abdomen in the same line until you detect the bottom edge of liver dullness. Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult. B. Splenic Dullness Percuss the lowest costal interspace in the left anterior axillary line. This area is normally tympanitic. Ask the patient to take a deep breath and percuss this area again. Dullness in this area is a sign of splenic enlargement.

Technique Liver Spleen

Percussion (technique)
DIP joint of third finger (pleximeter) pressed firmly on the abdomen remainder of hand not touching the abdomen

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

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.

To determine the size of the liver

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.

To determine the size of the liver

Move your hand down a few centimeters than you will be over the liver, which will produce a duller sounding tone.

To determine the size of the liver

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.

Shifting Dullness This is a test for peritoneal fluid (ascites). ++ Percuss the patient's abdomen to outline areas of dullness and tympany. Have the patient roll away from you. Percuss and again outline areas of dullness and tympany. If the dullness has shifted to areas of prior tympany, the patient may have excess peritoneal fluid. Psoas Sign This is a test for appendicitis. ++ Place your hand above the patient's right knee. Ask the patient to flex the right hip against resistance. Increased abdominal pain indicates a positive psoas sign. Obturator Sign This is a test for appendicitis. ++ Raise the patient's right leg with the knee flexed. Rotate the leg internally at the hip. Increased abdominal pain indicates a positive obturator sign.


General Palpation 1. Begin with light palpation. At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient's facial expression (so watch the patient's face, not your hands). Voluntary or involuntary guarding may also be present. 2. Proceed to deep palpation after surveying the abdomen lightly. Try to identify abdominal masses or areas of deep tenderness

Abdominal Palpation Technique Light Deep Liver edge Spleen tip Kidneys Aorta Masses

Abdominal palpation
To palpate four quadrants superficially from LLQ

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

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

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 Liver Kidney Abdominal aorta Iliac artery Distended bladder Gravid and nongravid uterus Xyphoid process 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).

Aabdominal wall mass

It will become more evident and palpable when patient flexes neck as this contracts rectus muscles.

Paraumbilical node

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

If there is tenderness determine the point of maximum tenderness and its distribution

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
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 (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

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.

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

Palpation of the Liver

Standard Method Place your fingers just below the right costal margin and press firmly. Ask the patient to take a deep breath. You may feel the edge of the liver press against your fingers. Or it may slide under your hand as the patient exhales. A normal liver is not tender. Alternate Method This method is useful when the patient is obese or when the examiner is small compared to the patient. Stand by the patient's chest. "Hook" your fingers just below the costal margin and press firmly. Ask the patient to take a deep breath. You may feel the edge of the liver press against your fingers.

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
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

Examination of Aorta

Flat palm placed over the the epigastrium to locate pulse

Examination of Aorta
Press down deeply in the midline above the umbilicus. 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 3 cm across, suggests an aortic aneurysm.

Examination of Aorta

Lateral width of pulsation is determined by space between index fingers


Special exam
Murphys Sign McBurneys Point Rovsings Sign Psoas Sign Obturator Sign
Re bound Tenderness Costovertebral tenderness Shifting Dullness 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