© continuing medical implementation …...bridging the care gap abdominal physical examination joel...

© Continuing Medical Implementation …...bridging the care gap

Abdominal Physical Examination

Abdominal Physical Examination

Joel Niznick MD FRCPC


AcknowledgementsAcknowledgements

• Adapted from Public Domain Web Slide-sets by:– Jim Pierce, MD– Luke Palmisano, MS III– Kamilee Christenson, MS II

– H.A.Soleimani MD


The History and Physical in Perspective

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. • Assess the acuity of the patient to focus your

differential diagnosis•


General principles of examGeneral principles of exam

• 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

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 patient’s face for discomfort.



Think Anatomically & Systemically

Think Anatomically & Systemically

• Inspection

• Auscultation

• Palpation

• Percussion

• Special maneuvers


General ObservationsGeneral Observations

• BMI, waist circumference, cachexia clubbing, jaundice, asterixis

• Eyes: Sclera (colour), conjunctiva (pallor)

• Head and neck: Spider nevi, dentition, fetor hepaticus, JVP, supraclavicular nodes

• Chest: gynecomastia, spider nevi

• Pheriphery: edema


Abdominal InspectionAbdominal Inspection

• Scars

• Scaphoid/Distension

• Masses

• Peristalsis

• Movement with respiration

• Venous distension

• Echymoses


Stigmata Chronic Liver Disease

Stigmata Chronic Liver Disease

• Clubbing

• Leukonychia

• Palmar erythema

• Dupuytren’s contracture

• Spider nevi

• Gynecomastia


Liver StigmataLiver Stigmata

• Testicular atrophy• Loss of axillary hair• Parotid enlargement• Ascites• Caput medusa• Peripheral edema


Liver StigmataLiver Stigmata


Signs of Hemorrhagic Pancreatitis

Signs of Hemorrhagic Pancreatitis

Grey-Turner’s Sign Cullen’s Sign


The Real InspectionThe Real Inspection


Scars and WoundsScars and Wounds


Pfannenstiel IncisionPfannenstiel Incision


Abdominal AnatomyAbdominal Anatomy

• Key Point: The Abdomen is 3D

– It has a top – the diaphragm– It has a front and sides – the abdominal wall– It has a back – the back and retroperitoneum– It has a bottom – the pelvis


The TOP of the AbdomenThe TOP of the Abdomen


Anterior Abdominal ExamAnterior Abdominal Exam


Abdominal Surface AnatomyAbdominal Surface Anatomy


Abdominal Deep AnatomyAbdominal Deep Anatomy

Liver

Gall bladderColonKidney

AppendixIBD massColon Ca

OvaryKidney Tx

BladderUterus

IBD MassColon CaStool mass

Ovary

StomachColonKidney

Spleen

PancreasPseudocyst

ColonAAA

Stomach


Anterior Abdomen:Auscultation

Anterior Abdomen:Auscultation

• Auscultate before palpation so as not to stimulate bowel sounds

• Auscultate for– Bowel Sounds: Hyperdynamic, Normal,

Occasional,Absent– Bruits / Hums– Rubs


Bowel SoundsBowel Sounds


Abdominal VasculatureAbdominal Vasculature


BruitBruit

• Bruits confined to systole do not necessarily indicate disease.


Auscultation for vascular bruitsAuscultation for vascular 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 bruitsAuscultation for vascular bruits

• When listening for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal structures.


RubsRubs


Rubs –Rubs-RubsRubs –Rubs-Rubs

• Liver

• Spleen

• Cardiac

• Pulmonary

• Right and left upper quandrants

• Grating sound with respiratory movement

• Indicates inflammation of the capsule of the liver or spleen (infection or infarction).


Venous Hum (rare)Venous Hum (rare)

• Epigastric/umbilical area.

• Soft humming noises in systolic/diastolic component.

• Indicates collateral between portal and venous systems as in hepatic cirrhosis.


Percussion versus PalpationPercussion versus Palpation

• Light Palpation assesses:– Masses and Tenderness in the Wall

• Deep Palpation assesses:– Masses and Tenderness in the Cavity

• Percussion assesses:– Location of organs– Location of masses – Deep tenderness


TendernessTenderness


• Inquire as to location of tenderness

• Start with light palpation away from tenderness

• Assess rigidity and guarding (voluntary/involuntary)

• Assess for rebound tenderness

• Palpate all 9 regions

Light PalpationLight Palpation


Deep PalpationDeep Palpation


Deep Palpation (alternatives)

Deep Palpation (alternatives)


Deep PalpationDeep Palpation

• Start in non-tender area-move towards tenderness

• Generally start in LLQ

• Palpate for masses and deep tenderness

• Palpate for organs– Liver, spleen, kidneys

• Palpate for AAA


Anterior Abdominal Exam:Percussion

Anterior Abdominal Exam:Percussion

• Nontender Abdomen– Location of Liver, Spleen– Succussion Splash of Stomach– Gas in Small / Large Intestine– Fluid in the Peritoneum

• Tender Abdomen– Location and Severity of Tenderness– Presence of signs of peritonitis

• Guarding, rigidity, rebound tenderness


Liver PalpationLiver Palpation

• Start in RLQ/MCL• Move hand up as

patient inspires• Gradually move

position up towards costal margin with each inspriation

• Feel for liver edge as patient inspires

• Normal liver edge smooth and soft

• Describe liver edge if abnormal– Hard/firm/nodular

• Normal liver 10-12 cm in MCL

• Percuss top of liver in held inspiration

• Scratch test


Liver palpation Liver palpation

•Hand held steady•Patient inhales

•Patient breathes•Hand lifted and moved up


Alternate Method Liver palpation

Alternate Method Liver palpation

• Stand by the patient's chest.

• "Hook" your fingers just below the costal margin and press firmly.


Hepatomegaly Hepatomegaly

• More than 1cm below the costal margin

• An exception is a congenitally large right lobe of the liver

• Severe, chronic emphysema pushes liver down


Pulsation transmitted from aorta or Pulsation transmitted from aorta or due to severe tdue to severe tricuspid valve ricuspid valve

insufficiencyinsufficiency

Pulsation transmitted from aorta or Pulsation transmitted from aorta or due to severe tdue to severe tricuspid valve ricuspid valve

insufficiencyinsufficiency


Hepatojugular reflux sign

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 signBallotable sign


Splenic palpationSplenic palpation

• Start in RLQ• Move hand up with

inspiration• Reposition on expiration• Migrate palpation

towards left costal margin

• Feel for notched splenic surface

• If spleen not felt roll patient in right decubitus position

• Support lrfy podterior costal margin with left hand and palpate under costal margin with right hand

• Percuss Traube’s space for dullness



• Seldom palpable in normal adults.

• Causes include COPD, and deep inspiratory descent of the diaphragm.



• 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.



• Deep technique used

• Starting point is RLQ, proceeding to LUQ


Kidney palpationKidney palpation

• Place left hand posteriorly just below the right 12th rib. Lift upwards.

• Palpate deeply with right hand on anterior abdominal wall.


Kidney palpationKidney palpation

• Patient take a deep breath.

• Feel lower pole of kidney and try to capture it between your hands.


Right kidney may be felt to slip between hands during exhalation

Right kidney may be felt to slip between hands during exhalation


Examination of AortaExamination 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 3 cm across, suggests an A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.aortic aneurysm.



• Lateral width of pulsation is determined by space between index fingers or finger and thumb


Abdominal Aortic AneurysmAbdominal Aortic Aneurysm

• Palpable pulsatile mass• Patient feeling of

pulsation• On rare occasions, a lump

can be visible.• May rupture leading to

shock and death• If ruptures into IVC =

continuous murmur


Abdominal examinationSpecial maneuvers

Abdominal examinationSpecial maneuvers


Special examSpecial exam

• Rebound Tenderness

• Murphy’s Sign • McBurney’s Point• Rovsing’s Sign• Psoas Sign• Obturator Sign

• Costovertebral tenderness

• Spinal percussion tenderness

• Shifting Dullness

• Fluid wave


Murphy’s Sign (acute cholecystitis)

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, Hepatitis, subdiaphragmaticsubdiaphragmatic abscess Cholecystitisabscess Cholecystitis


McBurney’s PointMcBurney’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)

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 SignRovsing’s Sign

• Patient will experience right lower quadrant pain (in region of McBurney’s Point) when left lower quadrant is palpated.


Non-Classical AppendicitisNon-Classical Appendicitis

• Iliopsoas Sign

• Obturator Sign


Iliopsoas SignIliopsoas 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 examiner’s hand on thigh. If patient has an inflamed retrocecal appendix, this will produce pain.


Iliopsoas SignIliopsoas 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 SignObturator 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.


Obturator SignObturator 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)

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.


Cost vertebral Tenderness (Often with renal disease)

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.


Posterior Abdominal Exam:Percussion

Posterior Abdominal Exam:Percussion


Examination for Shifting Dullness

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


Ascites / Liver DiseaseAscites / Liver Disease


Shifting DullnessShifting Dullness


Fluid WaveFluid Wave


Additional ExaminationsAdditional Examinations

• Inguinal hernia

• Femoral hernia


Additional examinationsAdditional examinations

Pelvic exam Rectal exam


Questions?Questions?

© continuing medical implementation …...bridging the care gap abdominal physical examination joel...

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