How to Examine the Heart - Continuing Medical Implementation Inc.
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Abdominal Physical Examination Joel Niznick MD FRCPC © Continuing Medical Implementation …...bridging the care gap Acknowledgements • Adapted from Public Domain Web Slide-sets by: – – – – Jim Pierce, MD Luke Palmisano, MS III Kamilee Christenson, MS II H.A.Soleimani MD © Continuing Medical Implementation …...bridging the care gap 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 …...bridging the care gap •© Continuing Medical Implementation General 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 © Continuing Medical Implementation …...bridging the care gap General principles of exam • If muscles remain tense, patient may be asked to rest feet on table with hips and knees flexed © Continuing Medical Implementation …...bridging the care gap 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 © Continuing Medical Implementation …...bridging the care gap General principles of exam • 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. © Continuing Medical Implementation …...bridging the care gap Think Anatomically & Systemically • • • • • Inspection Auscultation Palpation Percussion Special maneuvers © Continuing Medical Implementation …...bridging the care gap General 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 © Continuing Medical Implementation …...bridging the care gap Abdominal Inspection • • • • • • • Scars Scaphoid/Distension Masses Peristalsis Movement with respiration Venous distension Echymoses © Continuing Medical Implementation …...bridging the care gap Stigmata Chronic Liver Disease • • • • Clubbing Leukonychia Palmar erythema Dupuytren’s contracture • Spider nevi • Gynecomastia © Continuing Medical Implementation …...bridging the care gap Liver Stigmata • Testicular atrophy • Loss of axillary hair • Parotid enlargement • Ascites • Caput medusa • Peripheral edema © Continuing Medical Implementation …...bridging the care gap Liver Stigmata © Continuing Medical Implementation …...bridging the care gap Signs of Hemorrhagic Pancreatitis Grey-Turner’s Sign © Continuing Medical Implementation Cullen’s Sign …...bridging the care gap The Real Inspection © Continuing Medical Implementation …...bridging the care gap Scars and Wounds © Continuing Medical Implementation …...bridging the care gap Pfannenstiel Incision © Continuing Medical Implementation …...bridging the care gap © Continuing Medical Implementation …...bridging the care gap © Continuing Medical Implementation …...bridging the care gap Abdominal 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 © Continuing Medical Implementation …...bridging the care gap The TOP of the Abdomen © Continuing Medical Implementation …...bridging the care gap Anterior Abdominal Exam © Continuing Medical Implementation …...bridging the care gap Abdominal Surface Anatomy © Continuing Medical Implementation …...bridging the care gap Abdominal Deep Anatomy Stomach Pancreas Pseudocyst Colon AAA Liver Spleen Stomach Colon Kidney Gall bladder Colon Kidney IBD Mass Colon Ca Stool mass Ovary Appendix IBD mass Colon Ca Ovary Kidney Tx © Continuing Medical Implementation Bladder Uterus …...bridging the care gap Anterior Abdomen: Auscultation • Auscultate before palpation so as not to stimulate bowel sounds • Auscultate for – Bowel Sounds: Hyperdynamic, Normal, Occasional,Absent – Bruits / Hums – Rubs © Continuing Medical Implementation …...bridging the care gap Bowel Sounds © Continuing Medical Implementation …...bridging the care gap Abdominal Vasculature © Continuing Medical Implementation …...bridging the care gap Bruit • Bruits confined to systole do not necessarily indicate disease. © Continuing Medical Implementation …...bridging the care gap Auscultation 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) © Continuing Medical Implementation …...bridging the care gap Auscultation for vascular bruits • When listening for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal structures. © Continuing Medical Implementation …...bridging the care gap Rubs © Continuing Medical Implementation …...bridging the care gap Rubs –Rubs-Rubs • • • • Liver Spleen Cardiac Pulmonary © Continuing Medical Implementation • Right and left upper quandrants • Grating sound with respiratory movement • Indicates inflammation of the capsule of the liver or spleen (infection or infarction). …...bridging the care gap Venous Hum (rare) • Epigastric/umbilical area. • Soft humming noises in systolic/diastolic component. • Indicates collateral between portal and venous systems as in hepatic cirrhosis. © Continuing Medical Implementation …...bridging the care gap Percussion 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 © Continuing Medical Implementation …...bridging the care gap Tenderness © Continuing Medical Implementation …...bridging the care gap Light Palpation • 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 © Continuing Medical Implementation …...bridging the care gap Deep Palpation © Continuing Medical Implementation …...bridging the care gap Deep Palpation (alternatives) © Continuing Medical Implementation …...bridging the care gap Deep 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 © Continuing Medical Implementation …...bridging the care gap 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 © Continuing Medical Implementation …...bridging the care gap Liver 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 © Continuing Medical Implementation • 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 …...bridging the care gap Liver palpation •Hand held steady •Patient inhales © Continuing Medical Implementation •Patient breathes •Hand lifted and moved up …...bridging the care gap Alternate Method Liver palpation • Stand by the patient's chest. • "Hook" your fingers just below the costal margin and press firmly. © Continuing Medical Implementation …...bridging the care gap 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 © Continuing Medical Implementation …...bridging the care gap Pulsation transmitted from aorta or due to severe tricuspid valve insufficiency © Continuing Medical Implementation …...bridging the care gap 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. © Continuing Medical Implementation …...bridging the care gap Ballotable sign © Continuing Medical Implementation …...bridging the care gap Splenic palpation • Start in RLQ • Move hand up with inspiration • Reposition on expiration • Migrate palpation towards left costal margin • Feel for notched splenic surface © Continuing Medical Implementation • 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 …...bridging the care gap Splenic palpation • Seldom palpable in normal adults. • Causes include COPD, and deep inspiratory descent of the diaphragm. © Continuing Medical Implementation …...bridging the care gap Splenic palpation • Support lower left rib cage with left hand while patient is supine and lift anteriorly on the rib cage. © Continuing Medical Implementation …...bridging the care gap Splenic palpation • Palpate upwards toward spleen with finger tips of right hand, starting below left costal margin. • Have the patient take a deep breath. © Continuing Medical Implementation …...bridging the care gap Splenic palpation • Deep technique used • Starting point is RLQ, proceeding to LUQ © Continuing Medical Implementation …...bridging the care gap © Continuing Medical Implementation …...bridging the care gap Kidney palpation • Place left hand posteriorly just below the right 12th rib. Lift upwards. • Palpate deeply with right hand on anterior abdominal wall. © Continuing Medical Implementation …...bridging the care gap Kidney palpation • Patient take a deep breath. • Feel lower pole of kidney and try to capture it between your hands. © Continuing Medical Implementation …...bridging the care gap Right kidney may be felt to slip between hands during exhalation © Continuing Medical Implementation …...bridging the care gap Examination of Aorta • Flat palm placed over the the epigastrium to locate pulse © Continuing Medical Implementation …...bridging the care gap Examination of Aorta • Press down deeply in the midline above the umbilicus. • The aortic pulsation is easily felt on most individuals. © Continuing Medical Implementation …...bridging the care gap 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. © Continuing Medical Implementation …...bridging the care gap Examination of Aorta • Lateral width of pulsation is determined by space between index fingers or finger and thumb © Continuing Medical Implementation …...bridging the care gap Abdominal 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 © Continuing Medical Implementation …...bridging the care gap Abdominal examination Special maneuvers © Continuing Medical Implementation …...bridging the care gap Special exam • Rebound Tenderness • Murphy’s Sign • McBurney’s Point • Rovsing’s Sign • Psoas Sign • Obturator Sign © Continuing Medical Implementation • Costovertebral tenderness • Spinal percussion tenderness • Shifting Dullness • Fluid wave …...bridging the care gap 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 © Continuing Medical Implementation Hepatitis, subdiaphragmatic …...bridging the care gap abscess Cholecystitis McBurney’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. © Continuing Medical Implementation …...bridging the care gap 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 © Continuing Medical Implementation …...bridging the care gap Rovsing’s Sign • Patient will experience right lower quadrant pain (in region of McBurney’s Point) when left lower quadrant is palpated. © Continuing Medical Implementation …...bridging the care gap Non-Classical Appendicitis • Iliopsoas Sign • Obturator Sign © Continuing Medical Implementation …...bridging the care gap 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 examiner’s hand on thigh. If patient has an inflamed retrocecal appendix, this will produce pain. © Continuing Medical Implementation …...bridging the care gap 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. © Continuing Medical Implementation …...bridging the care gap 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. © Continuing Medical Implementation …...bridging the care gap 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. © Continuing Medical Implementation …...bridging the care gap 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. © Continuing Medical Implementation …...bridging the care gap 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. © Continuing Medical Implementation …...bridging the care gap Posterior Abdominal Exam: Percussion © Continuing Medical Implementation …...bridging the care gap 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 © Continuing Medical Implementation …...bridging the care gap Ascites / Liver Disease © Continuing Medical Implementation …...bridging the care gap Shifting Dullness © Continuing Medical Implementation …...bridging the care gap Fluid Wave © Continuing Medical Implementation …...bridging the care gap © Continuing Medical Implementation …...bridging the care gap Additional Examinations • Inguinal hernia • Femoral hernia © Continuing Medical Implementation …...bridging the care gap Additional examinations Pelvic exam © Continuing Medical Implementation Rectal exam …...bridging the care gap Questions? © Continuing Medical Implementation …...bridging the care gap
