Describing the Abdomen

Abdomen
split into
quadrants to
help organize
organs.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 5
Describing the Abdomen

The
abdomen
can also be
split into 9
sections as
well.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 6
Right Upper Quadrant (RUQ)

Liver & Gallbladder

Head of Pancreas

Duodenum

Right adrenal gland

Hepatic flexure of colon

Portion of right kidney
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 7
Right Lower Quadrant (RLQ)

Appendix

Ascending colon

Ovary

Right ureter

Bladder

Uterus
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 8
Left Upper Quadrant (LUQ)

Spleen

Stomach

Pancreas

Left lobe of liver

Splenic flexure of colon

Portions of transverse and descending colon
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 9
Left Lower Quadrant (LLQ)

Lower left kidney

Sigmoid colon

Ovary

Left ureter

Descending colon

Bladder

Uterus
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 10
Assessing the Abdomen

Chief complaint

History of present illness

Past medical history

Family history

Personal/Social history

Physical Exam

Differential

Labs
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 11
Importance of History Present Illness

GI versus cardiac causes

Clues to Differential

Abdominal “Review of Systems”

Seven attributes of a symptom
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 12
Review of Systems for the Abdomen

Abdominal pain

Constipation

Indigestion

Jaundice

Nausea

Dysuria

Vomiting

Urinary frequency

Diarrhea

Hematuria
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 13
• Review of Related History
Past Medical History

Gastrointestinal disorders

Urinary Tract Infections

Surgeries

Medications/Immunizations

Trauma/Injury

Blood transfusions

Hepatitis

Cancer
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 14
• Review of Related History
Family History

Familial Mediterranean Fever

Inflammatory bowel disease

Familial cancer syndromes

Congenital malformations

Cystic fibrosis, Celiac’s

Kidney disease

Gallbladder disease
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 15
• Review of Related History
Personal and Social History

Nutrition

LMP (first day of last menstrual period)

Stressful life events

Travel /Exposure to infectious diseases

Sexual history

Use of alcohol and/or illicit drugs

Tobacco use
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 16
• Review of Related History
Pregnant Women

Urinary symptoms




Frequency, urgency, burning, suprapubic pain
Back pain
Abdominal pain
Contractions


Onset, frequency, duration, intensity
Leakage of fluid, blood
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 17
• Review of Related History
Older Adults

Urinary Tract Infections

Constipation

Indigestion

Dietary habits
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 18
Abdominal Exam

Preparation

Inspection

Auscultation

Percussion

Palpation
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 19
Preparation for the Abdominal Exam

Empty bladder

Positioning

Abdomen exposure

Visualize anatomy

Warm hands & stethoscope

Approach from the right

Remember chief complaint

Watch face
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 20
Inspection (1)

Skin characteristics: color, striae, rashes,
lesions, scars, dilated veins

Umbilicus: location, displacement,
inflammation

Contour: rounded, flat, scaphoid

Symmetry: symmetric, bulges, distension

Surface Motion: pulsations, peristalsis
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 21
Auscultation

Bowel sounds: frequency, character

Vascular sounds: bruits, venous hums
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 22
Percussion (1)

Assess size & density of organs

Detect presence of fluid, air, masses,
tenderness

Can be done independently or concurrently
with palpation
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 23
Percussion (2)

All quadrants: tympany vs dullness

Liver span: at right MCL and at the MSL if
enlarged

Spleen percussion sign: lowest left ICS
before & after deep breath

Gastric bubble: left lower anterior rib cage,
left epigastric area

Kidneys: costovertebral angle
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 24
Percussion (3)

If suspect ascites as result of percussion of
abdominal wall may perform two additional
tests: Shifting Dullness Test and the Fluid
Wave Test
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 25
Palpation (1)

Evaluation of organs for: size, shape,
consistency, tenderness

Evaluate umbilical ring

Palpate for pulsation of abdominal aorta

Detection of masses
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 26
Palpation (2)

Light Palpation: all 4 quadrants; identify
muscular resistance, tenderness, masses

Deep palpation: all 4 quadrants; delineate
organs and detect deeper masses

Mass: location, size, shape, consistency,
tenderness, pulsation, mobility, movement
with respiration, superficial or intra-abdominal
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 27
Palpation (3)

Liver: palpate lower border of right costal
margin

Aorta: for pulsation

Bladder: distension

Gallbladder, Spleen, Kidney not often done
unless physician suspects abnormality
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 28
• Examination and Findings
Additional Abdominal Tests

Rebound tenderness

Iliopsoas muscle test

Obturator muscle test
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 29
Abdominal Signs/Associated
Conditions

Blumberg (rebound tenderness)

Cullen: ecchymosis around umbilicus

Grey Turner: ecchymosis of flanks

Kehr: abdominal pain radiating to left shoulder

Markel (heel jar test): up on toes, fall back on heels

McBurney: rebound tenderness,pain over appendix

Murphy: abrupt cessation of respiration when
gallbladder palpated
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 30
Differential by Anatomic Region-RUQ

Duodenal ulcer

Hepatomegaly

Hepatitis

Pneumonia

Cholecystitis
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 31
Differential by Anatomic Region-LUQ

Ruptured spleen

Gastric ulcer

Aortic aneurysm

Perforated colon

Pneumonia
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 32
Differential by Anatomic RegionPeriumbilical Region

Intestinal obstruction

Acute pancreatitis

Early appendicitis

Mesenteric thrombosis

Aortic aneurysm

Diverticulitis
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 33
Differential by Anatomic Region-RLQ

Appendicitis

Ovarian cyst or mass/salpingitis

Ruptured ectopic pregnancy

Renal/ureteral stone

Strangulated hernia

Perforated cecum/regional ileitis

Diverticulitis
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 34
Differential by Anatomic Region-LLQ

Ovarian cyst or mass/salpingitis

Ruptured ectopic pregnancy

Diverticulitis

Renal/ureteral stone

Strangulated hernia

Ulcerative colitis

Perforated colon/regional ileitis
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 35
Acute Appendicitis

Pain characteristic: periumbilical or
epigastric; later localized to RLQ, +McBurney

Associated findings: anorexia, nausea,
possible vomiting, low grade fever, guarding,
+rebound tenderness, +iliopsas, +obturator,
+McBurney, +Markle

Peritonitis possible if rupture occurs:
guarding, shallow respirations, hypotension
or shock, reduced or absent bowel sounds;
can be life-threatening
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 36
Acute Cholecystitis

Pain: severe pain in RUQ, epigastric or
umbilical pain; lasting 2-4 hours; after meals
and especially after fatty meal; may be
referred to right subscapular area

Associated findings: RUQ tenderness &
rigidity, +Murphy sign, palpable gallbladder,
anorexia, vomiting, flatulence, fever; possible
jaundice
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 37
Acute Pancreatitis

Pain: dramatic, sudden, excruciating LUQ,
epigastric, or umbilical pain; may be present
in one or both flanks with possible
ecchymosis; pain may be referred to left
shoulder

Associated findings: epigastric tenderness,
vomiting, fever, shock; +Grey Turner and
Cullen signs which occur 2-3 days after onset
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 38
Ectopic Pregnancy

Pain: history of vague abdominal pain
followed by sudden severe abdominal
tenderness in LQ, especially on involved side

Associated findings: hypogastric tenderness,
symptoms of pregnancy, spotting, missed
period, mass on bimanual pelvic exam; if
ruptured: shock, rigid abdominal wall,
distension, + Kehr, + Cullen

Mittleschmertz: pain associated w/ovulation
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 39
Acute Hepatitis

Pain: general abdominal discomfort; malaise

Associated findings: jaundice, clay-colored
stools and dark urine which may preceed
jaundice by 1 to 5 days, enlarged liver

Patients with cirrhosis: will also have ascites,
prominent abdominal vasculature, cutaneous
spider angiomas, generalized itching
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 40
Perforated Gastric or Duodenal Ulcer

Pain: abrupt RUQ; may be referred to
shoulders

Associated findings: abdominal free air and
distension with increased resonance over
liver; tenderness in epigastrum or RUQ; rigid
abdominal wall, rebound tenderness;
hematemesis, melena, hypotension,
increased pulse rate; “acute abdomen” is a
life-threatening event
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 41
Abdominal Aortic Aneurysm

Pain: painless but pain may indicate
imminent rupture; steady throbbing midline
pain over aneurysm which may radiate to
back, flank

Associated findings: nausea, vomiting,
prominent aortic pulsation, bruit and or mass

Life-threatening even if occurs in hospital
setting
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 42
Pyelonephritis

Pain: flank pain, back pain

Associated findings: malaise, dysuria,
nocturia, urinary frequency, possible fever, +
costovertebral angle tenderness
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 43
Renal Calculi

Pain: intense flank pain extending to groin &
genital area; may be episodic

Associated findings: fever, hematuria, + Kehr
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 44
Irritable Bowel Syndrome

Pain: crampy, variable hypogastric pain;
associated with abdominal bloating,
distension; + bowel sounds

Associated symptoms: flatus, constipation or
diarrhea; may see mucous in stool; relief with
passage of flatus or bowel movement
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 45
Diverticulitis

Pain: epigastric, radiating down left side of
abdomen especially after eating; may be
referred to back

Associated findings: tenderness on
palpation, borborygmus, flatulence, diarrhea,
possibly dysuria
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 46
Acute Diarrhea

Pain: abrupt onset of crampy pain

Associated findings: increased bowel
sounds, diarrhea, nausea, vomiting, fever,
and tenesmus; consider food poisoning if
develops in 2 or more following ingestion of
same food
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 47
Hernia

Pain: localized pain that increases with lifting
or exertion

Associated findings: hernia on physical
exam, history of abdominal trauma, surgery
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 48
References



Mosby’s Guide to Physical Examination, 6th
Edition. Chapter 17 pp 521-578.
Bates’ Guide to Physical Examination and
History Taking. Chapter 9 pp 317-366.
University of California, San Diego “A
Practical Guide to Clinical Medicine”
Accessed online 02/09/07 at
medicine.ucsd.edu/clinicalmedicine/
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.
Slide 49