Abdominal Exam

Abdominal Exam

General

  • Wash your hands upon entering the room
  • Introduce yourself and the exam to the patient in a way that the patient will understand
  • Patient should be supine on a flat bed
  • Drape the patient so the abdomen is exposed from the nipple line to at least the anterior superior iliac spine (ASIS)

Vital Signs

Vital signs should be measured on every patient. They include:

  • Blood pressure
  • Heart rate
  • Respiratory rate
  • Temperature
  • Oxygen saturation may also be included

Inspection

When inspecting the abdomen, you should be looking for the following things:

  • General appearance
    • Does the patient look sick? Are they in any obvious distress?
    • Note the patient's body habitus
  • Visible masses
    • Splenomegaly can be seen as a mass extending from the left upper quadrant to the right lower quadrant
  • Scars

 Figure 1: Locations of common surgical scars. 1 = Choleocystectomy, 2 = Laparotomy, 3 = Appendectomy, 4 = Pelvic Surgery, 5 = Inguinal Hernia Repair

Figure 1: Locations of common surgical scars. 

1 = Choleocystectomy, 2 = Laparotomy, 3 = Appendectomy, 4 = Pelvic Surgery, 5 = Inguinal Hernia Repair 

  • Pulsations
    • Visible pulsations in the epigastric area may represent an abdominal aortic aneurysm but may be normal in a thin patient
  • Skin changes
    • Skin discoloration such as jaundice
      • Best seen in the sclera as scleral icterus
    • Obvious lesions, eccymoses, Cullen's or Grey Turner's sign
      • Cullen's Sign - Periumbilical bruising and edema sugests hemorrhage or acute pancreatitis
      • Grey Turner's Sign - Flank bruising and edema suggests retroperitoneal hemorrhage or acute pancreatitis
  • Ascites
    • Best seen from the foot of the bed as bulging flanks

Liver Disease Inspection

There are specific stigmata of liver disease that should be inspected for. It is helpful to approach these stigmata in a systematic way. Here, they are presented starting in the hands, working up to the head and then down to the legs.

  • Nails
    • Leuconychia - White base of the nail. Commonly seen in the thumb and index finger. Also referred to as Terry's nails
    • Clubbing - Examine for Schamroth's sign: Ask the patient to oppose their distal phalanges from opposite hands. A positive sign represents the absence of a diamond shape between the fingers
  •  Hands
    • Palmar erythema - Examine the thenar and hypothenar eminences for redness
    • Dupuytren's contracture - Flexion of the fingers caused by thickening and contraction of the palmar fascia 
    • Thenar wasting - Examine for wasting of the thenar eminence
    • Asterixis - Ask the patient to hold their hands out in front of their face. Observe for a "flapping" of their hands. This suggests hepatic encephalopathy
  • Face
    • Frontal balding
    • Temporal muscle wasting - Examine for any obvious wasting of the temporalis muscle
    • Scleral icterus - Check for yellowing of the sclera, suggesting jaundice (see figure 2 above)
    • Oral petechiae
    • Fetor hepaticus - Note the presence of a sweet, fecal odorous breath, representing the presence of ammonia and ketones
  • Chest
    • Telengectasias or spider nevi - Balanchable red spots with extensions radiating outward. Most commonly found on the chest or face
    • Gynecomastia - Enlargement of the breasts in men. Often associated with changes in hair distribution
  • Abdomen
    • Caput medusae - Engorged superficial veins radiating out from the umbilicus
    • Ascites - Best observed from the foot of the bed as bulging flanks
  • Genitalia
    • Testicular atrophy
  • Legs
    • Peripheral edema

Auscultation

Contrary to other physical exams, auscultation should be performed before percussion and palpation for the abdominal exam. This is because palpation and percussion may displace abdominal the contents.

  • Bowel sounds
    • Auscultate using the diaphragm in all 4 quadrants for bowel sounds
    • Normal sounds are low pitched rumbling sounds every 5-10 seconds
    • High frequency bowel sounds may suggest a bowel obstruction
    • Examiners must listen for at least 2 minutes before declaring that bowel sounds are absent
  • Bruits
    • Auscultate using the diaphragm for bruits over the abdominal aorta, renal arteries, common iliac arteries, femoral arteries, and over the liver.

Percussion

Percussion of the abdomen consists of 4 components: General percussion, percussion of the liver span, percussion of the spleen, and tests for ascites.

  • General percussion
    • Percuss in all 4 quadrants
      • Normal -  Tympanic to percussion, dullness may represent a solid mass
      • Abnormal - Dullness may represent a solid mass, hyperresonance may represent the presence of gas due to a bowel obstruction
  • Percuss the liver span
    • Percuss down the right midclavicular line starting at the clavicle. The point at which the percussion note changes from resonant to dull is the upper liver border
    • Percuss up the right midclavicular line starting in the right lower quadrant. The point at which the percussion note changes from tympanic to dull is the lower liver border
    • The distance between these two points is the liver span.
      • Normal - Male = 10-12cm, Female = 8-10cm

 Figure 2: Percussion of the liver span

Figure 2: Percussion of the liver span

  • Percussion of the spleen
    • There are 2 methods for percussing the spleen for enlargement:
    • Castell's Method
      • Percuss in the 9th intercostal space at the anterior axillary line on the left side. As the patient to breathe in and hold it as you percuss. 
        • Normal - Resonance to percussion throughout inspiration
        • Splenic Enlargement - Percussion note changes from resonant to dull during inspiration
      • Caution: This test may produce a false positive if the patient has eaten within the last 4 hours
    • Traube's Space
      • Percuss in a triangle bordered by the 6th rib, costal margin, and anterior axillary line on the left side.
        • Normal - Resonance to percussion throughout
        • Abnormal - Dullness to percussion, suggesting splenic enlargement

 Figure 3: Percussion of the spleen by Traube's Space (Left) and Castell's Sign (Right)

Figure 3: Percussion of the spleen by Traube's Space (Left), and Castell's Sign (Right) 

  • Detecting ascites
    • There are 2 methods for detecting ascites: Shifting dullness and the fluid wave test.
    • Shifting dullness
      • Percuss laterally down the abdomen from the umbilicus listening for the percussion note to change from tympanic to dull. Mark the location
      • Ask the patient to lie in the lateral decubitus position and repeat the percussion.
        • Normal - Position of the transition from tympanic to dull does not move with position
        • Ascites - Position of transition from tympanic to dull moves up the abdomen with the patient in the lateral decubitus position

 Figure 4: Shifting dullnes technique

Figure 4: Shifting dullness technique

    • Fluid wave test
      • Ask the patient to place the radial side of their hand on the midline of their abdomen
      • Place your hands on either side of the patient's abdomen. Tap on one side of the patient's abdomen and feel for the transmission of the wave using your other hand.
        • Normal - No fluid wave can be palpated
        • Ascites - A fluid wave can be palpated with the non-tapping hand

 Figure 5: Fluid wave test technique

Figure 5: Fluid wave test technique

Palpation

Before palpating, ask the patient if they have any tenderness. Palpate any tender areas last.

  • Light palpation
    • Palpate lightly in all 4 quadrants.
    • Pay attention to the patient's face for signs of pain. Be aware of guarding (a tense abdominal wall)
    • While palpating, note any abdominal wall abnormalities such as a hernia
  • Deep palpation
    • Palpate deeper in all 4 quadrants.
    • Pay attention to the patient's face for signs of pain.
    • While palpating, note any obvious masses, or areas of fullness in the abdomen
  • Palpate the liver edge
    • Ask the patient to take deep breaths
    • Starting in the right lower quadrant, press inward and upward as the patient inspires. When the patient expires, advance your hand upward toward the costal margin. You are feeling for the liver edge to brush against your fingers as you apply pressure.
    • It is normal not to feel the liver edge in healthy individuals
    • Murphy's Sign
      • Positive Sign - The patient abruptly interrupts inspiration as the examiner palpates the gallbladder (just below the costal margin in the midclavicular line). This suggests cholecystitis

Figure 6: Direction of palpation for the liver

Figure 6: Direction of palpation for the liver

  • Palpate for an enlarged spleen
    • The spleen enlarges from the left upper quadrant to the right lower quadrant
    • Ask the patient to take deep breaths
    • Starting in the right lower quadrant, press inward and toward the left upper quadrant as the patient inspires. When the patient expires, advance your hand toward the left upper quadrant. You are feeling for the splenic border brush against your fingers as you apply pressure.
    • It is normal not to palpate the spleen in healthy individuals

Figure 7: Direction of palpation for the spleen

Figure 7: Direction of palpation for the spleen

  •  Ballottement of the kidneys
    • Place one hand behind the patient's back just below the costal margin
    • Place your other hand on the patient's abdomen and press down
    • Try to capture the inferior pole of the kidney between your two hands
      • The kidneys are usually non-palpable in normal adults, except in thin patients
  • Digital rectal examination (DRE) - Not required in ASCM1
    • A rectal examination should be performed as part of all complete abdominal examinations
    • Palpate for rectal tone, tenderness, and prostate size and texture. Also note the presence of blood on the glove

Tests for Peritoneal Irritation

 

  • Inspection
    • The patient will likely be in discomfort. Classically, they prefer to remain still and may report that the car ride to the hospital was particularly uncomfortable
      • Cough tenderness - Ask the patient to cough. This will often elicit pain
      • Point tenderness - Ask the patient to point to where they feel pain
  • Percussion
    • Percussion of the abdomen may elicit tenderness
    • In appendicitis, this tenderness may be maximal over McBurney's point (1/3 of the distance from the ASIS to the umbilicus)
  • Palpation
    • Before palpating, ask the patient where they have tenderness. Palpate any tender areas last. The patient may also present with guarding. Asking the patient to flex their legs may relieve some of the abdominal tension
    • General palpation 
      • May elicit tenderness over a specific area
    • Rebound tenderness - For peritoneal irritation
      • Press deeply over the suspected area for a few seconds, then release the pressure quickly.
        • Positive Sign - Patient reports that the pain is more severe when the pressure is released
    • Rovsing's Sign - For appendicitis
      • Positive Sign - Pain in the right lower quadrant upon palpation in the left lower quadrant
    • Psoas Sign - For appendicitis
      • Positive Sign - Pain on extension of the right hip
    • Obturator Sign - For appendicitis
      • Positive Sign - Pain on internal rotation of the right hip
    • Digital Rectal Examination - For an inflamed appendix inferior to the cecum
      • Positive Sign - Tenderness

References:

1:Fred, H., & van Dijk, H. (2008, December 8). Images of Memorable Cases. Retrieved from the Connexions Web Site: http://cnx.org/content

2:Courtesy Desherinka, Wikimedia Commons: http://upload.wikimedia.org/wikipedia/commons/c/cd/Acopaquia.jpg

3:Courtesy James Heilman, Wikimedia Commons: http://upload.wikimedia.org/wikipedia/commons/2/21/Dupuytren%27s2010.jpg

4:Courtesy James Heilman, Wikimedia Commons: http://upload.wikimedia.org/wikipedia/commons/8/84/Combinpedal.jpg