3 session 3_abdominalexam

8/10/2019 3 Session 3_AbdominalExam

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Session 3: Abdominal Exam

Information type Examples

What constitutes a normal physical exam

finding

Where (anatomically) structures are

normally located, including helpful

external landmarks

What a normal structure looks like

(visual appearance), feels like

(palpation), or sounds like

(auscultation, percussion)

The total span of the normal liver is quite variable,

depending on the size of the patient (between 6 and 12 cm)

Spleen percussion should yield a tympanic sound. The

normal spleen in not palpable in adults.

When palpating the left and right lower quadrants , the

ovaries and fallopian tubes are not identifiable unless

pathologically enlarged.

Right kidney is slightly lower than left kidney

Normally kidneys are not palpable. A right kidney may be

palpable in a thin person that is well relaxed. However, youMAY be able to palpate the kidneys in infants.

You can usually palpate liver edge in most infants/children

1-2cm below right costal margin, its sharp and soft.

What constitutes an abnormal physical

exam finding

Size limitsbeyond which a structure is

enlarged

Abnormal locationsof structures

Abnormal appearances, textures, or

sounds associated with examination

of a structure

A liver span larger than 12 cm is considered enlarged.

Abdominal Aorta greater than roughly 3 cm wide is

enlarged

When enlarged the spleen tends to grow towards the pelvis

and the umbilicus (i.e. both down and across)

Basic physiologic principles that affect

how structures look, feel, or sound like on

physical exam

n/a

The correct technique (using appropriate

landmarks)for performing a physical

exam maneuver

Preparing/Positioning Patient:

By convention the abdominal exam is performed with

provider standing on the patients right side.

Bladder should be empty (for comfort).

Patient should be comfortable in the supine position,

with bent knees and a pillow under the head. Another

pillow for under the knees may be helpful. (NOTE: Knees

that are slightly bent help to relax the abdominal muscles.


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Ask patient to point to any ares of pai and examine those

areas last.

Inspection: Assess shape/contour of abdomen (flat vs

concave, symmetric vs protrusions etc)

Note skin abnormalities ex; surgical scars, dilated veins,

rashes, lesions, striae.

Note patients movement/comfort or lack of.

For newborns and infantsassess the umbilical

cord/umbilicus for redness, swelling or hernia.

Auscultation:ALWAYS DO THIS BEFORE PERCUSSION and

PALPATIONso not to alter or artificially silence the bowelsounds.

AVOID listening through clothes.

Assess for presence or absence of bowel soundsNote the quality of the sound i.e., normal activity sounds

(NABS) vs. hypo/hyperactive sounds.

Assess for bruits; apply moderate pressure with

stethoscope over theepigastrium and all 4 quadrants.

Assessing the R/L renal arteries, R/L iliac arteries and the

R/L femoral arteries.

Use diaphragm of stethoscope to listen for renal artery

bruits a few cm above the umbilicus along the lateral edge

of either rectus muscles. Press down firmly.

PercussionAssess all quadrants noting areas of dullness vs.

tympany.

Measure the span (size) of the liver and spleen using

percussion.

By convention, the liver span is measured along the right

mid-clavicular line.

----

The spleen is posterior to the left mid-axillary line.

Percuss the left lower anterior chest wall,between lung resonance above and the costal

margin in the area known as Traubes space. Its

surface markings are the left sixth

rib

the left anterior axillary line, and the left costal margin.

Dullness on percussion of Traubes space is an indication of


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splenic enlargement. It should normally be tympanic.

Palpation:Warm your hands first.

Assess for tenderness to palpation (TTP) and/or masses

throughout the abdomen, first using gentle (shallow)

palpation, followed by deep palpation, including:

-Epigastrium

-Right upper quadrant (RUQ), including assessing the size

and contour of the liver and the liver edge

Use two hands bimanual palpation.

Support abdomen from below (using left hand)

Place fingers of opposite hand below border of liver

dullness. Have patient exhale then inhale. As patient

breathes in, push fingers down and back,

using a kneading or wave

motion, trying to feel the livers edge

as it comes to meet the finger tips.

Hooking Technique

Helpful, especially when patient is obese.

From top right of patient, place

both hands side by side on the right upper

abdomen, below the border of liver dullness. Press

inwards and upwards with the fingers to hook

over the costal margin. Then ask the patient take a

deep breath (into belly so as to push diaphragm

down).

-Left upper quadrant (LUQ), including assessment of the

spleen

Palpate with patient on right side, knees slightly flexed

(lateral decubitus position)

Reach left hand over and around patient to support

and press forward the lower left rib cage and adjacent

soft tissue. With the right hand below the costal

margin, press inward toward the spleen.

Ask patient to take a deep breath while the examiner

tries to feel the tip or edge of the spleen

(For all pediatric patients liver & spleen exams - be sure to

start palpation very low in abdomen/pelvis, moving

upwards.


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Techniques to relax infants while palpating abdomen:

Use Pacifier/bottle/gloved finger to elicit suck reflex

Hold legs flexed at hips/knees)

-Right lower quadrant (RLQ)

-Left lower quadrant (LLQ)

-Suprapubic region

-Abdominal aorta, including assessing its width-

Press firmly in the upper abdomen, slightly to the

left of midline.

Try to assess the width of the aorta by pressing

deeply in the upper abdomen with one hand on

either side of the aorta.

Palpating Kidneys:

Left kidneyOn patients left side, place right hand behind

patient just below and parallel to 12th rib,

fingertips just reaching costovertebral angle.

Lift, trying to displace kidney anteriorly, while

placing

left hand gently in left upper quadrant,

lateral and parallel to the rectus muscle.

While patient takes a deep breath, press the

left hand firmly and deeply into left upper

quadrant, to try to capture the kidney

between the two hands.

Right kidney:

On patients right side, use left hand to lift from

the back, and the right to press into the right

upper quadrant.

Perform the exam for the right kidney using a

similar technique as with the left kidney

Physical characteristics of the structure orappearance of body parts based on

normal, expected developmental

progression over time (i.e., age-related

changes/features)

Newborn and Young Infants:The kidneys and spleen tip are often palpable in infants.

Toddlers typically have a very protuberant abdomen,

lordotic stance, weak abdominal musculature and relatively

large abdominal organs

Umbilical hernias are common and usually a normal finding


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Diastasis Rectis aka abdominal separation:

Normal Findings from Power Point:

Structure Infants Young children

Liver Usually palpable

on exam

Soft

Edge is normally

Usually palpable on

exam

Soft

Edge is normally 1-2

in young children.

Diastasis rectia midline ridge at separation of 2 rectus

abdominis muscles - is common in Newborns and Infants.

See image below.

Differences in the normal physical examfindings in children compared to adults (if

mentioned in the assigned study

materials)

Mentioned above in other sections.
http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=FJIRGIG9jC0JGM&tbnid=yVl0Unk5iMRN9M:&ved=0CAUQjRw&url=http://newborns.stanford.edu/PhotoGallery/DiastasisRecti2.html&ei=uUkKUurNBOONygHg2YGQDQ&bvm=bv.50500085,d.b2I&psig=AFQjCNH_u1-s38Se6HlV9CVBLzQGNrmblA&ust=1376492308535800


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1-2 cm below

right costal

margin

Can be up to 3.5

cm below costal

margin in

healthy

newborns

cm below right costal

margin

Spleen Usually palpable in most

premature infants

Often palpable in term newborns

(15%)

Sometimes palpable,

esp. in younger

children

10% of healthy young

children

5% of healthy

adolescents

> 2cm below costal

margin is abnormal

Kidneys Normal kidneys often palpable in

flanks

Sometimes, but not usually palpable

Abdomina

l masses

Stool often palpable in LLQ (descending/sigmoid colon)

Spine easily palpable in thin children

Abdominal aorta easily palpable

Special Assessments from Wayne pdf:

Assessing for tenderness of the kidneys:

Place palm on posterior costal angle

Tap hand with other fist (fist percussion)

Assessing for peritoneal Inflammation:

Localize the pain as accurately as possible

Palpate gently with one finger to map the tender area


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If gentle palpation (or percussion) are not sufficient, assess for rebound tenderness ; pain

induced or worsened by withdrawal of hand when palpating . If present this suggests peritoneal

inflammation.

Assessing for Ascites:

If belly is distended, this assessment helps to determine whether air, fluid or stool is inthe belly.

Shifting dullness: More on this below in additional information section.

The air in belly will rise to top no matter the position of patient. Percuss first with patient l

ying face down, then with patient lying on side. Compare borders between tympany

and dullness. If no fluid is in belly the bowels will stay in the same place.

Fluid Wave: Tapping on one side of belly will create wave of fluid (if present), which will hitother hand on opposite flank. Important to use a third hand (either another examiners orpatients) to stabilize body fat so that does not create a wave that might obscure the fluid.

ADDITIONAL INFORMATION and IMAGES

OBSERVATION

Global abdominal enlargement is usually caused by air, fluid, or fat.


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Areas which become more pronounced when the patient valsalvas are often associated with ventral

hernias. These are points of weakening in the abdominal wall, frequently due to previous surgery,

through which omentum/intestines/peritoneal fluid can pass when intra-abdominal pressure is

increased.

The Valsalva maneuveror Valsalva manoeuvreis performed by moderately forceful attempted

exhalationagainst a closedairway,usually done by closing one's mouth, pinching one's nose shut while

pressing out as if blowing up a balloon.- Wikipedia

Various Causes of Abdominal Distension

Obese abdomen Hepatomegaly

AscitesMarkedly enlarged gall bladder

(labeled "GB")
http://en.wikipedia.org/wiki/Exhalationhttp://en.wikipedia.org/wiki/Exhalationhttp://en.wikipedia.org/wiki/Airwayhttp://en.wikipedia.org/wiki/Airwayhttp://en.wikipedia.org/wiki/Airwayhttp://en.wikipedia.org/wiki/Airwayhttp://en.wikipedia.org/wiki/Exhalation


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Umbilical Hernia

Same umbilical hernia while patient

performs valsalva maneuver.

Patient's movement (or lack thereof). Those with peritonitis (e.g. appendicitis) prefer to lie very still as

any motion causes further peritoneal irritation and pain. Contrary to this, patients with kidney stones

will frequently writhe on the examination table, unable to find a comfortable position.

AUSCULTATION

In the normal person who has no complaints and an otherwise normal exam, the presence or absence of

bowel sounds is essentially irrelevant (i.e. whatever pattern they have will be normal for them)

Bowel sounds can, however, add important supporting information in the right clinical setting. In

general, inflammatory processes of the serosa (i.e. any of the surfaces which cover the abdominal

organs....as with peritonitis) will cause the abdomen to be quiet (i.e. bowel sounds will be infrequent or

altogether absent). Inflammation of the intestinal mucosa (i.e. the insides of the intestine, as mightoccur with infections that cause diarrhea) will cause hyperactive bowel sounds.

Processes which lead to intestinal obstruction initially cause frequent bowel sounds, referred to as

"rushes." Think of this as the intestines trying to force their contents through a tight opening. This is

followed by decreased sound, called "tinkles," and then silence.

PERCUSSION:

There are two basic sounds which can be elicited:

1. Tympanitic (drum-like) sounds produced by percussing over air filled structures.2. Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies

beneath the region being examined.

*Special note should be made if percussion produces pain, which may occur if there is underlying

inflammation, as in peritonitis.


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Percussion can be quite helpful in determining the cause of abdominal distention, particularly in

distinguishing between fluid (a.k.a. ascites) and gas. Of the techniques used to detect ascites,

assessment for shifting dullness is perhaps the most reliable and reproducible. This methoddepends on the fact that air filled intestines will float on top of any fluid that is present. Proceed

as follows:

1. With the patient supine, begin percussion at the level of the umbilicus and proceed downlaterally. In the presence of ascites, you will reach a point where the sound changes from

tympanitic to dull. This is the intestine-fluid interface and should be roughly equidistantfrom the umbillicus on the right and left sides as the fluid layers out in a gravity-

dependent fashion, distributing evenly across the posterior aspect of the abdomen. It

should also cause a symmetric bulging of the patient's flanks.

2. Mark this point on both the right and left sides of the abdomen and then have the patientroll into a lateral decubitus position (i.e. onto either their right or left sides).

3. Repeat percussion, beginning at the top of the patient's now up-turned side and movingdown towards the umbilicus. If there is ascites, fluid will flow to the most dependent

portion of the abdomen. The place at which sound changes from tympanitic to dull willtherefore have shifted upwards (towards the umbillicus) and be above the line which you

drew previously. Speed percussion (described above) may also be used to identify thelocation of the air-fluid interface. If the distention is not caused by fluid (e.g. secondaryto obesity or gas alone), no shifting will be identifiable.

Shifting Dullness (real patient)


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Realize that there has to be a lot of ascites present for this method to be successful as the abdomen and

pelvis can hide several hundred cc's of fluid that would be undetectable on physical exam. Also, shiftingdullness is based on the assumption that fluid can flow freely throughout the abdomen. Thus, in cases of

prior surgery or infection with resultant adhesion formation, this may not be a very useful technique.

Palpation can also be used to check for ascites (see below).

PALPATION

Start in the right upper quadrant, 10 centimeters below the rib margin in the mid-clavicular line. This

should insure that you are below the liver edge. In general, it is easier to detect abnormal if you start in

an area that you're sure is normal

As the kidney lies in the retroperitoneum, pounding gently with the bottom of your fist on the costo-

vertebral angle (i.e. where the bottom-most ribs articulate with the vertebral column) will cause pain if

the underlying kidney is inflamed. Known as costo-vertebral angle tenderness (CVAT), it should be

pursued when the patient's history is suggestive of a kidney infection (e.g. fever, back pain and urinary

tract symptoms).


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ASSESSING FOR FLUID WAVE:

When observation and/or percussion are suggestive of ascites, palpation can be used as aconfirmatory test. Ask the patient or an observer to place their hand so that it is oriented

longitudinally over the center of the abdomen. They should press firmly so that the subcutaneoustissue and fat do not jiggle. Place your right hand on the left side of the abdomen and your left

hand opposite, so that both are equidistant from the umbillicus. Now, firmly tap on the abdomen

with your right hand while your left remains against the abdominal wall. If there is a lot of

ascites present, you may be able to feel a fluid wave (generated in the ascites by the tappingmaneuver) strike against the abdominal wall under your left hand. This test is quite subjective

and it can be difficult to say with assurance whether you have truly felt a wave-like impulse.

FINDINGS COMMONLY ASSOCIATED WITH ADVANCED LIVER DISEASE:

Chronic liver disease usually results from years of inflamation, which ultimately leads to fibrosis and

decline in function. Histologically, this is referred to as Cirrhosis. This can be driven by a number of

different processes, most commonly chronic alcohol use, viral hepatitis (B or C) or hemachromatosis

(the complete list is much longer). It's important to realize that a cirrhotic liver can be markedly enlarged

(in which case it may be palpable) or shrunken and fibrotic (non-palpable).

1. Hyperbilirubinemia: The diseased liver may be unable to conjugate or secrete bilirubinappropriately. This can lead to

a. Icterus - Yellow discoloration of the sclera.


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b. Jaundice - Yellow discoloration of the skin.

c. Bilirubinuria - Golden-brown coloration of the urine.

2. Ascites: Portal vein hypertension results from increased resistance to blood flow through an

inflamed and fibrotic liver. This can lead to ascites, accumulation of fluid in the peritoneal cavity.


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3. Increased Systemic Estrogen Levels: The liver may become unable to process particular

hormones, leading to their peripheral conversion into estrogen. High levels promote:

a. Breast development (gynecomastia).

b. Spider Angiomata - dilated arterioles most often visible on the skin of the upper chest.

c. Testicular atrophy.

4. Lower Extremity Edema: Impaired synthesis of the protein alburmin leads to lower intravascular

oncotic pressure and resultant leakage of fluid into soft tissues. This is particularly evident in the

lower extremities.


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Edema

5. Varices: In the setting of portal hypertension, blood "finds" alternative pathways back to the

heart that do not pass through the liver. The most common is via the splenic and short gastric

veins, which pass through the esophageal venous plexus enroute to the SVC. This causes

esophageal varices which can bleed profoundly, though these are not apparent on physical

examination. A much less common path utilizes the recanalized umbilical vein, which directs

blood through dilated superficial veins in the abdominal wall. These are visible on inspection of

the abdomen and are known as Caput Medusae.

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