Physical Examination
ABDOMEN
RULE #1
POSITION
• The patient should be lying flat on bed
• Arms on the sides
exposure
•From the level of nipples
to the level of knees.
Don’t forget to :
• Have warm hands and a warm stethoscope.
• Avoid quick, unexpected movements.
• Distract the patient with questions.
• Monitor your examination by watching
patient's face.
Abdominal examination
•Abdomen
•Back
•PR / PV
inspection
1. Contour and symmetry :
) ‫(قابلوني اذا شفتوها‬Flat abdomen
Inspection
2. Scars :
a.
Location
b. Length
c.
Color
Inspection
• 3. skin / dilated veins :
Striae prolonged stretching of
the skin; seen in ascites,
obesity, tumor, pregnancy,
and Cushing's Syndrome
Spider angioma
Inspection
• 4. umbilicus:
a.
Contour
b. Location
c.
Signs of hernia - lifting head or coughing
Turner’s sign
Inspection
• 5. masses / enlarged organs :
hepatomegaly
Inspection
• 6 Peristalsis
• 7 . Distribution of Pubic Hair (Escutcheon):
a. Female distribution - triangle with base above
the symphysis
b. Male distribution - diamond with upper
vertex extending as high as the umbilicus
• 8. respiration pattern :
female : thoracoabdominal
Male : abdominothoracic
Inspection
• 9. epigasric pulsation :
AAA
• https://www.youtube.com/watch?v=CQzjJQm
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RULE #2
• If it was your mother lying
on the bed , would you do
the same thing ?
Auscultation
• You must auscultate before you percuss or
palpate abdomen because these maneuvers
may alter the frequency of bowel sounds.
Enhanced peristaltic sounds may mask other
abnormal abdominal sounds such as bruits
and friction rubs.
Auscultation
• 1. Bowel sounds - listen and note frequency
and character (normal sounds consist of clicks
and gurgles and occur 5 to 34 per minute)
. Absence of bowel sound - established
only after 5 minutes of continuous listening.
Caused by an immobile bowel of adynamic ileus
(peritonitis, severe hypokalemia, complete
obstruction, paralytic ileus, gangrene). A full
bladder can obscure sounds.
Auscultation
• 2. Vascular Sounds :
Location
Over abdominal aorta
Renal arteries
Right upper quadrant
Indication
Atherosclerosis
Aneurysm
Aortic compression by a tumor
Renal artery stenosis (check for hypertension)
Vascular tumor of the liver (Hepatoma, Hemangioma)
Iliac arteries
Atherosclerosis
Femoral arteries
Atherosclerosis
Auscultation
• Sounds :
https://www.youtube.com/watch?v=ZoXbHvFhb
i0&list=PL37B77CC6BEDF3DEB
RULE #3
Percussion
• Percussion of the abdomen helps assess for intestinal
distention, free fluid, solid masses, hepatomegaly, and
splenomegaly.
contraindicated
• It is
in patients with AAA ,
organ transplants or injured spleen.
• Percussion for beginners :
https://www.youtube.com/watch?v=P4Ryk5IKf_4 •
•
Percussion
• Abdominal organs
• Liver – percuss up from RIF then down from
right side of chest to determine the size of the
liver
Spleen – percuss up from RIF moving
towards the LUQ to assess for splenomegaly
Bladder – percuss suprapubic region –
differentiating suprapubic masses (bladder
(dull) / bowel (resonant))
Percussion
• Shifting dullness
• 1. Percuss from the centre of the abdomen to the flank until
dullness is noted
2. Keep your finger on the spot at which the percussion note
became dull
3. Ask patient to roll onto the opposite side to which you have
detected the dullness
4. Keep the patient on their side for 30 seconds
5. Repeat your percussion in the same spot
6. If fluid was present (ascites) then the area that was
previously dull should now be resonant
7. If the flank is now resonant, percuss back to the midline,
which if ascites is present, will now be dull (i.e. the dullness
has shifted)
Percussion
• Liver :
https://www.youtube.com/watch?v=D0G7353qf
Yw
https://www.youtube.com/watch?v=LmNQGKvT
ck0
Percussion
• Spleen :
https://www.youtube.com/watch?v=hhvGnBUN
Cgo
. Shifting dullness :
https://www.youtube.com/watch?v=b7glKxy7Vv
I
RULE #4
•BE patient with
patients who are not
patient .
Palpation
• Remember:
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•
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The pads and tips (the most sensitive areas) of the index, middle, and ring fingers
are the examining surfaces used to locate the edges of the liver and spleen as well
as the deeper structures
Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely
to startle the patient or cause discomfort .
Examine each quadrant separately, imagining what structures lie beneath your
hands and what you might expect to feel.
In general, it is easier to detect abnormal if you start in an area that you're sure is
normal.
Ask if the patient has any pain anywhere before you begin!
Look at patients face throughout the examination for signs of discomfort.
Palpation
• 1. Light palpation :
• Assess each of the four quadrants for the
following…
Tenderness – note the areas involved and the severity of the
pain
Rebound tenderness – pain is worsened on releasing
the pressure – peritonitis
Guarding – involuntary tension in the abdominal muscles –
assess if localized or general
Masses – large / superficial masses may be noted on light palpation
Palpation
• 2 .Deep palpation
• Assess each of the four quadrants again, but
with greater pressure on palpation
• 1.liver
• 2. gallbladder
• 3. spleen
• 4 .Kidneys
• 5 . Aorta
• 6 .Bladder
• Liver
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Palpation
1. Start palpation in the right iliac fossa
2. Press your right hand into the abdomen
as you ask the patient to take a deep breath
3. Feel for a step, as the liver edge passess
below your hand
4. If you don’t feel anything, repeat the
process with your hand 1-2 cm higher .
If you feel the liver edge, note the
following:
Degree of extension below the costal margin
Consistency of the liver edge
(smooth/irregular)
Tenderness – suggestive of hepatitis
Pulsatility – a pulsatile enlarged liver can be
caused by tricuspid regurgitation
Palpation
• Gallbladder
• The gallbladder is not usually palpable when healthy
• An enlarged gallbladder suggests obstruction to biliary flow /
infection (cholecystitis)
• Perform palpation at the right costal margin, midclavicular line (9th rib tip)
• If enlarged, a round mass, moving with respiration may be
palpated – note any tenderness
•
• Murphys sign:
• Place your hand in the area noted above
• Ask the patient to take a deep breath
• As the gallbladder is pushed down into your hand they may
suddenly develop pain & stop inspiring
• This is a positive Murphy’s sign, which is suggestive of cholecystitis
Palpation
• Spleen
•
The spleen is not usually palpable, therefore if
you feel it, it’s at least
it’s normal size!
1. Start in right iliac fossa – as massive
splenomegaly can extend this far!
2. Align your fingers in the same direction
as the left costal margin
3. Press your right hand into the abdomen
as you ask the patient to take a deep
breath
4. Feel for a step, as the splenic edge
passess under your hand (a notch may be
noted) – note position
5. If you don’t feel anything, repeat
process with your hand 1-2 cm closer to
the LUQ
3x
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Palpation
• Kidneys
• 1. Place your left hand behind the
patients back at the right flank
• 2. Place your right hand just below the
right costal margin in the right flank
• 3. Press your right hands fingers deep
into the abdomen
• 4. At the same time press upwards with
your left hand
• 5. Ask the patient to take a deep breath
• 6. You may feel the lower pole of the
kidney moving inferiorly during
inspiration
• 7. Repeat this process on the opposite
side to assess the left kidney
•
Palpation
• Aorta
• 1. Palpate using fingers
from both hands
• 2. Palpate just above the
umbilicus at the border
of the aortic pulsation
• 3. Note the movement of
your fingers:
• Upward
movement = pulsatile
• Outward movement
= expansile (suggestive of
AAA
Palpation
• Bladder
• An empty bladder will not be
palpable (pelvic)
However an enlarged full bladder can
be felt arising from behind the pubic
symphysis
This may suggest a diagnosis of
urinary retention
Palpation
• https://www.youtube.com/watch?v=aSPqXd9
PILo
PR/GENETALIA !!!
• Say you would carry out the following if
appropriate…
• Check hernial orifices – e.g. if there’s
signs of obstruction
Perform a digital recta
examination (PR)– e.g. if there’s a
suggestion of UGIB
Perform an examination of the external
genitalia .
Don’t forget to :
1.Thank patient
2. Wash hands
3. Summarize findings .
DDx
• Think Anatomically: When looking,
listening, feeling and percussing imagine what
organs live in the area that you are examining.
The abdomen is roughly divided into four
quadrants: right upper, right lower, left upper and
left lower. By thinking in anatomic terms, you will
remind yourself of what resides in a particular
quadrant and therefore what might be
identifiable during both normal and pathologic
states
All the best