ABDOMINAL PHYSICAL DIAGNOSTIC

INTRODUCTION

• Introduce your self• Explain what you're going to do• Have the patient empty their bladder before examination• Have the patient lie in a comfortable, flat, supine position• Exposing only the area that are being examined • During the exam pay attention to their facial expression to

assess for sign of discomfort• Use warm hand, warm stethoscope, and have short finger

nails

ABDOMINAL REGIO

• When looking, listening, feeling and percussing imagine what organs live in the area that you are examining

Physical Examination of the Abdomen

Inspection

Auscultation

PercussionPalpation

Other Tests

INSPECTION

General inspection

• Flat or Scaphoid (Normally)

• Distended/enlargement air, fluid, fat, mass, gravida Symmetric/ asymmetric

• Aortic pulsation/Aneurism• Peristaltic• Scar/cicatrix• Striae/tatto• Cullen sign/turner sign

SCAR / CICATRIX

AUSCULTATION

•Bowel sounds •Vascular sounds (bruits)•Fetal movement & heart sound

TARGET

It is performed before percussion or palpation

Auscultation

• Listening in one spot is usually sufficient (30-60”)• Cannot be said to be absent unless they are not heard for

at least 3-5 minutes.• Normal : 6-10 peristaltic/min • Decrease :

– Inflammatory processes of the serosa–After abdominal surgery – In response to narcotic analgesics or anesthesia

• Hyperactive– Inflammation of the intestinal mucosa– intestinal obstruction

Bruit location

PERCUSSION

Percussion (technique)

• DIP joint of third finger (pleximeter) pressed firmly on the abdomen remainder of hand not touching the abdomen

• Use the same technique during pulmonary examination

• Two basic sound : tympanic vs dullness

Determine the size of the liver

• Measure the liver span by percussing hepatic dullness from above (lung) and below (bowel). A normal liver span is 6 to 12 cm in the midclavicular line

Spleen percussion

• Enlarged spleen produce a dull tone, in the left upper quadrant percussion but should then be verified by palpation.

Shifting Dullness

• Percuss from anterior abdomen laterally to outline areas of dullness

• Patient rolled slightly toward the examined side; the dullness area will move/shift to medially suggests ascites

PALPATION

General principle

• First warm your hands• Any areas of pain or tenderness

are reserved for evaluation at the end of the exam

• Patient may be asked to rest feet on table with hips and knees flexed

Technique :• Use palmar surface of fingers of one hand (greatest number

of fingers) and a deep, firm, gentle maneuver to examine abdomen

• Palpate deeply with finger pads (do not “dig in” with finger tips)

• Either one or two handed technique is acceptable

Normal structure that may be palpable

• Sigmoid colon • Liver• Kidney• Abdominal aorta• Iliac artery

• Distended bladder• Gravid and non-

gravid uterus • Xyphoid process• Spleen

Type of abdominal pain

• Arises from an organic lesion or functional disturbance

• Dull, poorly localized• Sometime referred

Visceral pain

• Sharp, bright, and well localized • Involvement of parietal peritoneum,

abdominal wall or skin itself Somatic pain

REFFERED PAIN

REFFERED PAIN

Board-like rigidity

• If abdominal wall is palpated as obviously tense, even as rigid as a board board-like rigidity = defans muscular

Caused by the spasm of abdominal muscle due to peritoneal irritation peritonitis

Liver palpation

• Palpating hand is held steady while patient inhales lifted and moved while the patient breathes out

• Hepatomegaly : > 1cm below the costal margin

• An exception : severe, chronic emphysema

Always palpating from low down, so very large livers are not missed

Alternate Method Liver palpation

• Stand by the patient's chest.

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

• Is useful when the patient is obese or when the examiner is small compared to the patient

Hepatojugular reflux sign

• Pressing the liver will raise jugular vein pressure becomes more bulged or distended,

• Sign of the enlargement of liver passive congestion due to right heart failure.

Spleen palpation

• 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. • Seldom palpable in normal

adults. • Normal palpable in COPD, and

deep inspiratory

Slight spleenomegaly

Other spleen palpation maneuver

• Castell’s point : normally empty (= tympanic )

• Traube’s space : normally empty

Hackett’s classification of splenomegaly

Class Findings on palpation0. Spleen not palpable even on deep

inspiration.

1. Spleen palpable below costal margin, usually on deep inspiration.

2. Spleen palpable, but not beyond a horizontal line half way between the costal margin and umbilicus, measured in a line dropped vertically from the left nipple.

3. Spleen palpable more than half way to umbilicus, but not below a line horizontally running through it.

4. Palpable below umbilicus but not below a horizontal line half way between umbilicus and pubic symphysis.

5. Extending lower than class 4.

Kidney palpation

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

• Palpate deeply with right hand on anterior abdominal wall.

• Patient take a deep breath. • Feel lower pole of kidney

and try to capture it between your hands.

• Normal kidney rarely palpable

BIMANUAL PALPATION OF THE KIDNEY

Examination of Aorta

• Press down deeply in the midline above the umbilicus.

• The aortic pulsation is easily felt on most individuals old, thin

A well defined, pulsatile mass, > 3 cm across, suggests an aortic aneurysm.

Murphy’s Sign

• 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

• Posible : hepatitis, subdiaphragmatic abscess, cholecystitis

•

McBurney’s Point

• Localized tenderness 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 Pain

Common Causes• Appendicitis • Incarcerated or

strangulated hernia • Ovarian torsion (twisted

Fallopian tube) • Pelvic inflammatory

disease • Abdominal abscess • Diverticular disease • Meckel's diverticulum

Costo-vertebral Tenderness

• Use the heel of your closed fist to strike the patient firmly over the costovertebral angles.

• Compare the left and right sides.

• Commonly a clue for renal disease

= Undulation

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.

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.

Other maneuver

• Rovsing’s Sign : patient will experience right lower quadrant pain (McBurney’s Point) when left lower quadrant is palpated

• Rebound Tenderness–Warn the patient what you are about to do. –Press deeply on the abdomen with your hand. –After a moment, quickly release pressure hurts more when

you release

CIRRHOSIS