ABDOMINAL PHYSICAL DIAGNOSTIC

INTRODUCTION

Introduce your self Explain what you're going to do Have the patient empty their bladder before examination Have the patient lie in a comfortable, flat, supine position Exposing only the area that are being examined 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

ABDOMINAL REGIO

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

Inspection

Other Tests

Auscultation

Palpation

Percussion

INSPECTION

General inspection
Flat or Scaphoid (Normally) Distended/enlargement air, fluid, fat, mass, gravida Symmetric/ asymmetric Aortic pulsation/Aneurism Peristaltic Scar/cicatrix Striae/tatto Cullen sign/turner sign

SCAR / CICATRIX

AUSCULTATION

TARGET

Bowel sounds Vascular sounds (bruits) Fetal movement & heart sound
It is performed before percussion or palpation

Auscultation

Listening in one spot is usually sufficient (30-60) Cannot be said to be absent unless they are not heard for at least 3-5 minutes. Normal : 6-10 peristaltic/min Decrease :
Inflammatory processes of the serosa After abdominal surgery In response to narcotic analgesics or anesthesia

Hyperactive
Inflammation of the intestinal mucosa intestinal obstruction

Bruit location

PERCUSSION

Percussion (technique)

DIP joint of third finger (pleximeter) pressed firmly on the abdomen remainder of hand not touching the abdomen Use the same technique during pulmonary examination Two basic sound : tympanic vs dullness

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

Spleen percussion Enlarged spleen produce a dull tone, in the left upper quadrant percussion but should then be verified by palpation.

Shifting Dullness

Percuss from anterior abdomen laterally to outline areas of dullness Patient rolled slightly toward the examined side; the dullness area will move/shift to medially suggests ascites

PALPATION

General principle
First warm your hands Any areas of pain or tenderness are reserved for evaluation at the end of the exam Patient may be asked to rest feet on table with hips and knees flexed

Technique : 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)

 Either one or two handed technique is acceptable

Normal structure that may be palpable Sigmoid colon Liver Kidney Abdominal aorta Iliac artery
Distended bladder Gravid and nongravid uterus Xyphoid process Spleen

Type of abdominal pain

Arises from an organic lesion or functional disturbance Dull, poorly localized Sometime referred

Visceral pain

Somatic pain

Sharp, bright, and well localized Involvement of parietal peritoneum, abdominal wall or skin itself

REFFERED PAIN

REFFERED PAIN

Board-like rigidity
If abdominal wall is palpated as obviously tense, even as rigid as a board board-like rigidity = defans muscular Caused by the spasm of abdominal muscle due to peritoneal irritation peritonitis

Liver palpation
Palpating hand is held steady while patient inhales lifted and moved while the patient breathes out Hepatomegaly : > 1cm below the costal margin An exception : severe, chronic emphysema

Always palpating from low down, so very large livers are not missed

Alternate Method Liver palpation

Stand by the patient's chest. "Hook" your fingers just below the costal margin and press firmly. Is useful when the patient is obese or when the examiner is small compared to the patient

Hepatojugular reflux sign

Pressing the liver will raise jugular vein pressure becomes more bulged or distended, Sign of the enlargement of liver passive congestion due to right heart failure.

Spleen palpation
Support lower left rib cage with left hand while patient is supine and lift anteriorly on the rib cage. 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. Normal palpable in COPD, and deep inspiratory

Slight spleenomegaly

Other spleen palpation maneuver

Castells point : normally empty (= tympanic ) Traubes space : normally empty

Hacketts classification of splenomegaly

Class Findings on palpation
0. Spleen not palpable even on deep inspiration. 1. Spleen palpable below costal margin, usually on deep inspiration. 2. Spleen palpable, but not beyond a horizontal line half way between the costal margin and umbilicus, measured in a line dropped vertically from the left nipple. 3. Spleen palpable more than half way to umbilicus, but not below a line horizontally running through it. 4. Palpable below umbilicus but not below a horizontal line half way between umbilicus and pubic symphysis. 5. Extending lower than class 4.

Kidney palpation
Place left hand posteriorly just below the right 12th rib. Lift upwards. Palpate deeply with right hand on anterior abdominal wall. Patient take a deep breath. Feel lower pole of kidney and try to capture it between your hands. Normal kidney rarely palpable

BIMANUAL PALPATION OF THE KIDNEY

Examination of Aorta Press down deeply in the midline above the umbilicus. The aortic pulsation is easily felt on most individuals old, thin

A well defined, pulsatile mass, > 3 cm across, suggests an aortic aneurysm.

Murphys Sign
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 Posible : hepatitis, subdiaphragmatic abscess, cholecystitis

McBurneys Point
Localized tenderness 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 Pain
Common Causes
Appendicitis Incarcerated or strangulated hernia Ovarian torsion (twisted Fallopian tube) Pelvic inflammatory disease Abdominal abscess Diverticular disease Meckel's diverticulum

Costo-vertebral Tenderness
Use the heel of your closed fist to strike the patient firmly over the costovertebral angles. Compare the left and right sides. Commonly a clue for renal disease

= Undulation

Obturator Sign

Internally rotate right leg at the hip with the knee at 90 degrees of flexion. Will produce pain if inflamed appendix is in pelvis.

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.

Other maneuver
Rovsings Sign : patient will experience right lower quadrant pain (McBurneys Point) when left lower quadrant is palpated Rebound Tenderness
Warn the patient what you are about to do. Press deeply on the abdomen with your hand. After a moment, quickly release pressure hurts more when you release

CIRRHOSIS