Abdo exam

General Abdo Exam

• Preparation

  • Position:

    • Lying flat on the back with abdominal muscles relaxed

    • Flatten the bed or examining table, rest the patient’s head on a pillow, and ask the patient to keep his/her arms at his/ her sides. 

  • Draping

    • Drape the patient so that the abdomen is visible from just below the nipples to at least the pubic bone (pubic symphysis).

• Inspection

  • General appearance 

    • i.e. comfort level, signs of distress, rigidity/ restlessness

    • Guarding of abdominal muscles

  • Jaundice (look at the sclera and frenulum of the tongue)

  • Contour and symmetry of abdomen:

    • Distended abdomen

    • Scaphoid (concave)

    • Visible organs, masses, pulsations

  • Ascites (look for bulging flanks from the foot of the bed)

  • Peristalsis (may be normal in very thin people).

  • Masses and scars (previous surgeries)

  • Hypertrophy, atrophy, scars, skin lesions or dilated veins (while a few small may be normally visible, dilated veins are suggestive of hepatic cirrhosis or inferior vena cava obstruction.

  • Ecchymosis (hemorrhagic spots):

    • Periumbilical –Cullen’s Sign, indicative of pancreatitis

    • Flank –Grey Turner’s Sign (you must look at the patient’s side/back to see this), indicative of pancreatitis

• Auscultation (must be performed before percussion and palpation)

  • Bowel sounds

    • Use diaphragm of stethoscope

    • Listen over peri-umbilical area

    • Note if present or absent

    • Bowel sounds (borborygmi) typically occur every 5–10 seconds and consists of ‘clicks and gurgles’

    • Must listen for at least one minute before concluding that bowel sounds are absent

    • Bowel sounds absent:

      • complete small bowel obstruction

      • ileus (functional bowel obstruction)

      • conditions that lead to peritonitis

    • Bowel sounds high pitched:

      • partial small bowel obstruction

  • Vascular bruits:

    • high-pitched sounds caused by turbulent blood flow within arteries due to stenosis or tortuosity

    • Listen over the major arteries in the abdomen:

      • Abdominal aorta (2 cm above the umbilicus)

      • Renal arteries (2 cm on either side of the abdominal aorta)

      • Iliac arteries (halfway between umbilicus and ASIS on both sides)

      • Femoral arteries (halfway between ASIS and pubic symphysis)

• Percussion

  • Percuss the central abdomen and all four quadrants 

  • Normal = tympanic (drum-like sound)

  • Dullness:  solid structures (e.g. liver, spleen, mass, pregnant uterus, stool) or fluid (e.g. ascites, distended bladder)

  • Hyper-resonance:  may occur in bowel obstruction

• Palpation

  • Voluntary guarding 

    • Result of patient’s fear of pain rather than the actual pain itself

    • Distracting the patient or relaxation techniques may partially or fully eliminate the guarding. 

  • Involuntary guarding (rigidity)

    • A reflexive spasm of the abdominal muscles due to peritonitis (peritoneal inflammation) and as such it cannot be overcome.

  • General palpation

    • Begin palpation away from any area of pain – do any painful areas last

    • Palpate all 4 quadrants using both light and deep palpation

    • Using light palpation, try to identify areas of tenderness/guarding

    • Using deep palpation, try to identify masses or areas of fullness

  • Rebound tenderness

    • Increased pain on quick release of deep abdominal palpations suggests peritonitis

  • Carnett’s sign

    • While palpating the point of maximal tenderness, ask patient to raise both of their legs up off the bed (alternatively, the patient raise their head off the bed). 

    • This causes tensing of the abdominal wall muscles. 

    • If pain stays the same or gets worse, this indicates abdominal wall pain. 

      • Examples: anterior cutaneous nerve entrapment syndrome, hernias, myositis

    • If pain gets better, this suggests an intra-abdominal source of pain.

  • Palpate the abdominal aorta by placing both hands on either side of the umbilicus.

    • A palpable mass with expansile pulsations ≥ 3cm in diameter could indicate an abdominal aortic aneurysm.

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• Extra tests

  • Palpating the kidneys

    • Place one hand under the patient’s back at the level of the umbilicus

    • With your other hand, press down into the abdomen at the level of the umbilicus and attempt to palpate the kidney

    • Repeat on the other side

    • Check for costovertebral angle (CVA) tenderness by placing the fist of one hand on the CVA and tapping on that fist with the other fist.

      • If this causes pain/tenderness it could indicate infection.

    • Note: Kidneys are not usually palpable in adults, except in very thin patients

  • Murphy’s sign:

    • Palpate in the right upper quadrant just below the costal margin in the mid-clavicular line

    • Ask the patient to inspire

    • If the patient stops their breath suddenly due to tenderness, this is suggestive of cholecystitis

Liver Exam

• Preparation

  • Position:

    • Lying flat on the back with abdominal muscles relaxed

    • Flatten the bed or examining table, rest the patient’s head on a pillow, and ask the patient to keep his/her arms at his/ her sides. 

  • Draping

    • Drape the patient so that the abdomen is visible from just below the nipples to at least the pubic bone (pubic symphysis).

• Inspection (signs of liver disease, head to toe)

  • Head & Neck

    • Level of consciousness

    • Appropriateness of speech & thought

    • Jaundice (scleral icterus)

    • Muscle wasting of temporalis

    • Fetor hepaticus (musty, fecal-smelling breath)

    • Parotid enlargement (alcohol-related)

    • Frontal balding (men)

  • Hands & arms

    • muscle wasting of deltoids, thenars

    • Petechiae, purpura, spider angiomas

    • Terry's nails, leukonychia (white nails), clubbing

    • Asterixis (ask the patient to extend their wrists with arms extended in front of them, with their eyes closed, and look for intermittent asymmetric loss of extensor tone)

    • Dupuytren's contracture (thickening of palmar fascia over the 4th or 5th fingers - alcohol related)

    • Palmar erythema (men)

  • Chest

    • Gynecomastia (men)

    • Loss of axillary hair (men)

    • purpura, spider angiomas

  • Abdomen

    • Small/large liver

    • Splenomegaly

    • Ascites (bulging flanks, distention)

    • Dilated superficial and periumbilical veins (caput medusae)

    • Easy bruising/petechaie

  • Pelvis

    • Testicular atrophy, loss of male pattern hair (pubic hair)

  • Legs

    • Muscle wasting

    • Peripheral edema

• Percussion

  • Percuss for the liver span in the right mid-clavicular line from the bottom up and top down, marking where dullness begins in both directions 

  • If necessary, you may ask female patients to hold their right breast out of the way, to ensure that you start in a resonant area.

  • A normal liver span by percussion is 6-12 cm (longer in men and taller people)

  • The liver span may be artificially increased due to dullness in the right lung (effusion or right middle lobe consolidation) and decreased with gas within the hepatic flexure of the colon. When the liver grows, it expands from the RUQ to the RLQ.

• Palpation

  • To palpate for the liver edge begin in the right LOWER quadrant, slightly superior to the inguinal ligament

  • Proceed superiorly along the right mid-clavicular line

  • Direct the patient’s breathing

  • Attempt to ‘catch’ the liver edge during inspiration

• Auscultation

  • Not a standard part of the liver exam

  • Under certain circumstances, may consider listening for bruits (hepatomas), friction rubs (tumour, hepatitis) and venous hums (continuous, low-pitched sounds due to portal hypertension)

Spleen Exam

• Preparation

  • Position:

    • Lying flat on the back with abdominal muscles relaxed

    • Flatten the bed or examining table, rest the patient’s head on a pillow, and ask the patient to keep his/her arms at his/ her sides. 

  • Draping

    • Drape the patient so that the abdomen is visible from just below the nipples to at least the pubic bone (pubic symphysis).

• Inspection

  • Splenomegaly – a bulging mass may be seen emerging from under the left costal margin and extending diagonally towards the right lower quadrant

• Percussion

  • Traube’s space:

    • Percuss in the area bounded by the left anterior axillary line, 6th rib, and the costal margin

    • This area should be resonant on percussion, dullness indicates possible splenic enlargement

    • Other causes of dullness: food within 2 hours, a large left pleural effusion.

  • Castell’s method:

    • Percuss in the lowest left intercostal space on the anterior axillary line (usually the 8th or 9th space) while the patient inhales deeply

    • This space should remain resonant during full inspiration, dullness on full inspiration indicates possible splenic enlargement (a positive Castell’s sign).

    • This method is only valid if the patient has not eaten in the last 4 hours

• Palpation

  • Begin in right lower quadrant

  • Direct the patient’s breathing by telling him/her when to take a deep breath and when to exhale

  • While proceeding diagonally towards the left upper quadrant, try to catch the spleen edge during each inspiration

  •  If you experience difficulty palpating the edge of the spleen, repeat the exam while placing your left hand under patient’s left posterior chest and pulling upwards

Exam for Ascites

• Inspection

  • Bulging flanks from the foot of the bed

  • Peripheral edema

  • Stigmata of liver disease (see liver exam)

• Palpation

  • Palpate the abdomen 

    • Soft vs tense from distension

  • Pitting edema of ankles/legs

• Percussion

  • Flank dullness

    • With ascites, air-filled loops of bowel tend to float to the umbilicus when the patient is placed supine. This causes the flanks to fill with fluid and become dull

    • Place the patient supine and percuss the flanks bilaterally

    • Absence of flank dullness is suggestive of the absence of ascites

• Special maneuvers

  • Shifting dullness

    • Percuss at the centre of the abdomen and then continue toward the patient’s right flank, marking where the dullness begins

    • Roll the patient into the right decubitus position and repeat your percussion technique

    • In the case of ascites the area of dullness will shift upward as the fluid moves to fill the dependent side

  • Fluid wave test

    • Ask the patient to place the radial edge of their hand and their index finger in the head-to-toe direction in the centre of their abdomen

    • Place your hands on either side of the patient’s abdomen

    • Gently tap one side of the abdomen and feel for the tap on the other side

    • A palpable wave suggests ascites

Exam for Appendicitis

• Inspection

  • Does the patient look comfortable or uncomfortable?

  • Well or unwell?

  • Look for visible masses, asymmetry of the abdomen, contour, scars, bruising and signs of trauma.

• Palpation

  • McBurney’s Point is located in the right lower quadrant, one-third of the distance from the ASIS to the umbilicus. This approximates the base of the appendix. Tenderness of this point is McBurney’s sign and is a sign of acute appendicitis.

  • The ‘3-test’ approach to appendicitis includes: point tenderness, cough tenderness, and an attempt to examine the area of pain.

    • Point tenderness: patient points to McBurney’s point when asked to localize the pain.

    • Cough tenderness: patient has pain at McBurney’s point when asked to cough.

    • Attempt to examine the area of pain: patient has involuntary guarding on palpation of the RLQ.

• Other signs of appendicitis:

  • Rovsing’s sign

    • Palpate in the LLQ – increased pain in the RLQ suggests appendicitis

  • Psoas sign

    • 2 ways:

      1. Patient lies on left side; passively extending the patient’s right thigh to illicit pain in the RLQ. 

      2. Patient supine; ask patient to flex right leg at the hip against resistance to illicit pain in RLQ

  • Obturator sign

    • Pain on internal rotation of the right hip suggests an inflamed pelvic appendix

  • Rebound tenderness

    • Increased pain on quick release of deep abdominal palpations suggests peritonitis

  • Tenderness on digital rectal exam

    • Suggests inflamed appendix inferior to the cecum