SESSION 4 (February 16-20): The Physical Exam of the Abdomen

1. Apply health promotion and counseling to patients on topics such as alcohol abuse, hepatitis A, B,
C, and colon cancer
a. Risk Factors for liver disease most effective protection against HAV and HBV is vaccination
i. Hepatitis A ingestion of contaminated water/food (fecal-oral transmission)
1. Vaccination for pts with chronic liver disease, including HBV and HCV
ii. Hepatitis B parenteral (other than GI) or mucous membrane exposure to infections
body fluids; sexual transmission and IV drug use
1. >70% asymptomatic until liver disease is advanced
2. Vaccination when sexual contacts are infected, pts on dialysis, healthcare
workers
iii. Hepatitis C IV drug use or blood transfusion; most common blood-borne pathogen in
US
1. Chronic liver disease in >75% of those infected
2. Responsible for 50% of cirrhosis, end-stage liver disease, and liver cancer
3. Sexual transmission is rare
4. NO VACCINE
5. Prevention depends on screening and counseling to avoid risk factors
iv. Alcoholic Hepatitis or Alcoholic Cirrhosis DUI, pancretitis, family history of
alcoholism
1. 1 drink = 12 oz beer, 8 oz malt liquor, 5 oz wine, or 1.5 oz 80-proof spirit
a. Moderate drinking W (~1 per day) and M (~2 per day)
b. Maximum drinking W (~3 per day) and M (~4 per day)
c. Binge Drinking W (~4 per day) and M (~5 per day)
2. CAGE cut down? Annoyed? Guilty? Eye-opener?
2. Describe and demonstrate the proper techniques for assuring patient comfort for the abdominal
exam.
3. Demonstrate the proper technique for draping the patient for the abdominal exam.
4. Identify and describe the anatomical landmarks of the abdominal wall and pelvis.
a. Iliac crest (L4)
b. PSIS (S2)
c. Inguinal structures: NAVEL (Nerve, Artery, Vein, empty space, Lymph Node
5. Describe the location of the major organs in the abdomen using anatomic terms.
a. Quadrants, regions (epigastric, periumbilical, hypogastric, suprapubic)
6. Describe the sequence for performing the abdominal exam.
a. Inspection, Auscultation, Percussion, Palpation
7. Describe the normal and abnormal findings that can be detected with inspection of the abdomen.
a. Peristalsis (obstruction/skinny)
f. Rashes
b. Pulsations (aortic)
g. Ecchymoses
c. Scars
h. Contour/Symmetry of abdomen
d. Striae
i. Organs/masses
e. Dilated veins
8. Describe the technique of auscultation of the abdomen and describe normal and abnormal findings.
a. Quadrants
b. Liver and Spleen (friction rubs)
c. Aorta, renal, iliac, femoral arteries (Bruits)
9. Describe the technique of percussion in the abdominal exam and describe normal and abnormal
findings.
a. Quadrants
d. Spleen
b. Gastric bubble
e. Anterior chest
c. Liver
10. Describe the techniques of light and deep palpation in the abdominal exam and recognize normal and
abnormal findings.

a. Light palpation eliciting abdominal tenderness, muscular resistance, superficial

organs/masses
i. Distinguish between voluntary guarding and involuntary muscular spasm
1. Voluntary guarding decreases with:
a. Feel for relaxation of abdominal muscles on exhalation
b. Ask pt to mouth-breathe with jaw dropped
b. Deep palpation delineation of masses

i. Location, size, shape, consistency, tenderness, pulsations, mobility w/

respiration/pressure
11. Describe the maneuvers for the complete examination of the liver.
12. Describe the maneuvers for the complete examination of the spleen.
13. Describe the maneuvers for the complete examination of the kidneys.
14. Describe the maneuvers for assessing ascites, appendicitis, pyelonephritis, acute cholecystitis,
ventral hernias, and mass in the abdominal wall.
a. Assessing possible ascites
i. Protuberant abdomen with bulging flanks is suggestive
ii. Percuss in several directions from central area of tympany to border of dullness
1. Test for shifting dullness after percussing borders with patient supine,
percuss borders again with patient turned to one side
a. in ascites dullness shits to dependent side and tympany moves to top
b. in people w/o ascites the borders of dullness and tympany ~ stay the
same
2. Test for a fluid wave ask patient to press edges of both hands at midline
of abdomen to prevent pressure transmission through fat; tap one flank and
feel for impulse on other side (often negative until ascites is obvious)
iii. Identify mass in ascetic abdomen ballotte technique; jab fingers into abdomen to
displace fluid
b. Assessing possible appendicitis
i. Ask patient to cough and point where it hurts
ii. McBurneys point tenderness 2 inches from ASIS on diagonal line to umbilicus
iii. Guarding, rigidity, rebound tenderness (Blumberg Sign)
iv. Rovsings sign referred rebound tenderness; press deeply and quickly on LLQ
pain in RLQ
v. Psoas sign place hand on knee and ask patient to raise thigh against resistance;
may suggest irritation of psoas muscle by inflamed appendix
vi. Obturator sign flex right thigh at hip with knee bent and rotate internally at hip;
irritation of obturator muscle from inflamed appendix right hypogastric pain
vii. Carnetts sign pain when tensing abdominal wall muscles
viii. Rectal Exam or Pelvic Exam can distinguish between normal and inflamed
appendix; right sided rectal tenderness may be caused by inflamed adnexa (women)
or seminal vesicle
c. Assessing for pyelonephritis
i. Pain with pressure or fist percussion suggests pyelonephritis (or may be MSK)
d. Assessing possible acute cholecystitis
i. RUQ pain and tenderness
ii. Murphys Sign hook thumb under costal margin and ask patient to inhale deeply; a
sharp increase in tenderness with sudden stop of inspiratory effort suggests acute
choleystitis
e. Assessing for ventral hernias (umbilical or incicional)
i. Ask patient to lift head and shoulders off table bulge of hernia should appear
f. Mass in abdominal wall vs abdominal mass
i. Mass in wall remains palpable while intra-abdominal masses are obscured by muscle
contraction
ii. Ask patient to lift head and shoulders (or strain) which tightens abdominal muscles
15. Demonstrate the physical examination of the abdomen.