Medex Objectives Fall 2002

MEDEX Northwest Physician Assistant Objectives Home: http://faculty.washington.edu/alexbert/MEDEX/

Last updated 7 Dec 2003
GI Physical Examination Objectives
Goal: After learning the prescribed information, learning the prescribed abdominal exam and practicing it frequently, the
student should be able to identify and describe pathology associated with gastrointestinal system in any given patient.

1. Be able to describe the components of the GI Exam, and when and why portions are done.
See GI Branching Exam F5-F7
Fassil See Bates’ pg. 333-

2. Review the anatomy and physiology of the abdomen.

Zen Seeker

Anonymous
See Bates ch. 11, p 355
Brent K Bates 7th ed. p356-57
Know the anatomy and physiology of abdominal muscles, liver, gallbladder, colon (cecum, ascending, transverse, and
sigmoid), small intestine, duodenum, stomach, spleen, pancreas, kidneys, arteries, and bladder.
Fassil see Bates’ pg. 317

3. Identify normal structures that may be palpated in the abdomen.

Anonymous
• Xiphoid process
• Lower margin of the liver
• Lower part of the right kidney
• Abdominal aorta
• Cecum
• Ascending colon
• Transverse colon
• Descending colon
• Sigmoid colon
• Iliac arteries
• Sacral promontory-anterior edge of first sacral vertebra
• Full bladder
• Pregnant uterus
Anonymous
Sigmoid colon (LLQ)
Cecum, ascending colon (RLQ)
Transverse and descending colon (RLQ)
Lower margin of liver (RUQ)
Abdominal aorta (upper quadrants)
Sacral promontory (below umbilical)
Xiphoid process (epigastric, midline)
A distended bladder and pregnant uterus
AnonymousBates p. 356-357
sigmoid colon—firm narrow tube in LLQ
cecum, ascending colon—softer wider tube in RLQ
transverse, descending colon—portions may be palpable in upper and left Qs
liver edge—RUQ
lower pole of right kidney—deeper RUQ in thin person w/ relaxed abs.
abdominal aorta
iliac arteries
distended bladder—above pubic symphysis
pregnant uterus—above pubic symphysis
sacral promontory (edge of 1st sacral vertebra)—several cm below umbilicus in thin, relaxed
xiphoid process
tip of spleen—LUQ, only in very few adults
Brent K Bates 7th ed. p356-57
Normal palpated structures:
Sigmoid colon, cecum, part of the ascending colon, portions of the transverse colon, part of the liver, lower pole of the R
kidney can occasionally be palpated, abdominal aorta, iliac arteries, distended bladder, pregnant uterus, and sometimes the
sacral promontory (anterior edge of the 1st sacral vertebra).
Fassil Bates’ pg. 318
Sigmoid colon, cecum, part of ascending colon, portion of transverse and descending colon, the lower portion of liver,
kidneys, pulsation of abdominal aorta

4. Identify normal structures that are not normally palpable in the abdomen.
Anonymous
• Much of the liver
• Stomach
• Spleen (if normal)
• Gallbladder
• Duodenum
• Pancreas
• Most of kidneys
Anonymous
Most of the liver and stomach.
Spleen
Gallbladder
Pancreas
Duodenum
Kidneys
Anonymous Bates p. 356-357, 372
gallbladder
duodenum
pancreas
kidneys (see exception above)
Brent K Bates 7th ed. p 356-57
Normal structures not palpated:
Majority of the liver, stomach, spleen, gallbladder, duodenum, pancreas, and kidneys (except lower R pole).
Fassil Bates’ pg. 318

5. Identify a number of conditions that are essential or desirable for a good abdominal examination.
Zen Seeker
A. Conditions required:
A. Good light
B. Relaxed patient
C. Full exposure of abdomen
B. Other helpful points on examination
A. Should not have a full bladder.
B. Supine position.
C. Arms across chest, not above head.
D. Ask patient where pain is, and examine last.
E. If the patient is ticklish or frightened, initially use the patients hand under yours as you palpate. When
patient calms then use your hands to palpate.
F. 6. Watch the patient’s face for discomfort.
Anonymous
Good light.
Relaxed Pt.
Fully exposed pt. From xiphoid to symphysis pubis, groins visible, genitalia draped.
Empty bladder. (the pts’s, not yours)
Pt. should be supine, back flat, arms at sides.
Have pt. point to painful or tender areas.
Watch pt. face for signs of discomfort.
Your hands should be warm, warm stethoscope, short fingernails.
Examine slowly, avoid quick, unexpected movements.
Distract pt. If necessary.
Use pt’s hand if necessary to palpate beneath yours if pt. frightened or ticklish.
Brent K Bates 7th ed. p359
Full exposure of the abdomen from above the xiphoid to the symphysis pubis and a relaxed patient. To encourage
relaxation:
-empty bladder
-pillow for head and possible knees
-arms at sides or folded on chest to facilitate relaxation of the abdominal muscles
-examine tender or painful areas last
-observe pt for signs of discomfort
-warm hand and stethoscope, and short fingernails
-slow approach, avoiding quick unexpected movements
-distraction with conversation or questions
-If pt is frightened or ticklish, begin palpation with pt’s hand below yours
Fassil Bates’ pg. 332
For a good abd. Exam you need
• Good light
• A relaxed patient
• Full exposure of the abdomen from above the xiphoid process to the symphysis pubis.
• The groin should be visible
• The genitalia should be draped
Abdominal muscles should be relaxed

6. Identify the following as the correct order for examining the abdomen: inspection, auscultation, percussion,
and palpation, and why.
Zen Seeker
Order of exam
1. Inspection
2. Auscultation - always perform before palpation
3. Percussion
4. Palpation: light & deep
Anonymous
The abdomen should be auscultated prior to percussion or palpation because these maneuvers may change the
frequency of bowel sounds.
Sung K, Swartz p.443
The general sequence is out of order for the abdomen because it is believed that percussion or palpation may change
the intestinal motility and create increased or decreased bowel sounds. Therefore auscultation is performed earlier to
produce a more accurate assessment of the existing bowel sounds.

7. Describe items you would be examining for on inspection of the abdomen, and their possible significance.
Zen Seeker
A. Contour: is abdomen flat, swollen or bloated? Is there an area that is bulging or moving?
 B. Skin:
A. Strai (stretch marks): a streak or line, may be red, white, or purple. Dark pink-purple strai of Cushing
disease.
*Cushing disease: Cushing’s syndrome, in which the hypersecretion of glucocorticoids is secondary to
hypersecretion of adrenocorticotrophic hormone from the pituitary (Tabers Medical Dictionary, 1989).
B. Scars: location/appearence - describe or diagram their location.
C. Venous: dilation - seen in hepatic cirrhosis or inferior vena cava obstruction.
D. Color: areas of discoloration or rashes.
C. Umbilicus: contour, location, inflammation, hernia.
D. Contour of abdomen
A. Flat, rounded, protuberant or scaphoid.
B. Bulging flanks - seen in ascites.
C. Local bulges - pregnancy or distended bladder.
D. Symmetrical - asymmetry with enlarged organs or masses.
E. Visible organs or masses - lower abdominal masses of ovarian or uterine tumor.
E. Peristalsis: increased peristaltic waves of intestinal obstruction.
F. Pulsation: increased pulsation’s of aortic aneurysm.
*Aneurysm: Localized abnormal dilation of a blood vessel, usually an artery. Due to congenital defect or weakness
in the wall of the vessel.
G. Hernia:
*Hernia: Protrusion or projection of an organ or a part of an organ through the wall of the cavity that normally
contains it.
A. Abdominal - hernia through the abdominal wall.
B. Umbilical - bulging defect at umbilicus. Common in infants and generally closes by 3 y/o.
C. Incisional - defect in abdomen muscles after surgical incision. Must palpate the size of the defect.
D. Diastasis recti - not a true hernia, a separation or the two rectus abdominus muscles. No clinical
significance.
E. Epigastric - small, midline protrusion through a defect in the linea alba located between the xiphoid process
and umbilicus.
Anonymous
Skin: scars of old surgery, striae for the purple striae of Cushing’s syndrome, dilated veins of hepatic cirrhosis or inferior vena
cava obstruction, rashes.
The umbilicus: for contour and location, signs of herniation or inflammation.
Contour: for visible organomegally, pregnancy, ascites, bladder distension, symmetry,
Pulsation: increased aortic pulsation for aneurysm.
Sung K, Swartz p.440-2 and Barkauskas p.392-3
Inspect for Possible Significance
1. Contour a. Scaphoid a. associated with cachexia
b. Distention b. fluid, flatulence, fat, feces, fibroid tumor, fetus
c. Everted (the six f ’s).
umbilicus c. sign of ↑ abdominal pressure, e.g. ascited, large mass
2. Skin a. Pigmentation a. Grey Turner’s sign – ecchymoses as a result of hemorrhagic pancreatitis or
b. Lesions strangulated bowel.
c. Striae Cullen’s sign – bluish discoloration of the umbilicus suggesting periumbilical bleeding
d. Scars b. pearl-like enlarged umbilical node bay be related to intra-abdominal lymphoma. Tense
e. Superficial veins and glistening skin is often correlated with ascites or edema of abdominal wall.
f. Umbilicus c. pregnancy, abdominal tumor, ascites, obesity
d. previous surgery or trauma
e. vena cava or portal system obstruction
f. vena cava obstruction (dilated veins), umbilical hernia, metastatic carcinoma and
dampness or the smell of urine (patent urachus)
3. Movement a. Respiratory a. abdominal paradox, respiratory alternans
b. Visible b. bowel obstruction
peristalsis - small intestine: see ladder pattern
- large intestine: see upside down U.

8. Define the following terms: striae, scaphoid, borborygmi. (Medical Dictionary)

Anonymous
Striae: A stripe, streak strand or line distinguished by color, depression, elevation, or texture from the tissue in
which it is found.
Scaphoid: markedly concave or hollowed
Borborygmi: stomach growling sound, long prolonged gurgles of hyperperistalsis
Sung K, Swartz p.440 & Stedman Medical Dictionary
Striae – stretch marks usually located either on the flanks or lateral aspects of the abdomen. They may be multiple, 1-6
cm long, and are often encountered in other regions of chronic stretching (such as shoulders, thighs, and breasts). Although
they are usually due to rapid weight gain (or loss), they may represent simply a sequela of pregnancy. Silver striae stretch
marks consistent with weight loss. Pinkish purple striae are classic signs of adenocortical excess (e.g. Cushing’s disease,
excess steroid cream use on skin) since it is associated with erythrocytosis.
Scaphoid – a condition in which the anterior abdominal wall is sunken and presents a concave rather than convex
contour. This is associated with cachexia which is a general weight loss and wasting occurring in the course of a chronic
disease or emotional disturbance.
Borborygmi – rushes of low-pitched rumbling or gurgling noises produced by movement of gas, fluid, or both in the
alimentrary canal which are associated with hyperperistalsis.

9. Describe what you would be examining for on auscultation of the abdomen.

Zen Seeker
A. Bowel sounds (use diaphragm of stethoscope)
A. Bowel sounds are widely transmitted throughout the abdomen. Listening in one spot is usually sufficient.
B. Normal sounds are due to peristaltic activity.
*Peristalsis: A pregressice wavelike movement that occurs involuntarily in hollow tubes of the body.
 C. Normal sounds consist of clicks and gurgles.
D. Hypoactive bowel sounds are less than 3-4 sounds a minute.
E. Borborygmus - is the medical term for stomach growling. This is due to prolonged episodes of
hyperperistalsis. This is normal.
B. Abnormal bowel sounds: caused by a number of illnesses. There are several typically abnormal bowel sounds:
A. High pitched tinkling: usually due to tension of air/fluid in a loop of dilated bowel. This suggest obstruction.
B. Rushes: If located at one area, usually are due to air fluid being forced through small partially occluded
lumen. This suggest partial obstruction, especially if associated with concurrent abdominal activity.
C. Hyperactive: Sometimes normal if combined with abdominal complaints, can indicate early obstruction or
GI bleed.
D. Hypoactive or absent bowel sounds: Sometimes can be normal, but combined with complaints can indicate
paralytic ileus (a halt in peristaltic activity due to extreme irritation from obstructive peritonitis or unknown
reasons).
E. Bowel sounds cannot be said to be absent unless they are not heard after listening for 3 minutes.
C. Systolic Bruit: An adventitious sound of venous or arterial origin heard on auscultation. Use bell of stethoscope.
A. Listen at midline in middle of epigastrum for whooshing or blowing systolic noise indicative of turbulent
blood flow from arterial plaques or aortic aneurysm. Important to listen for if patient has vascular
insufficiency of the lower extremities.
B. Listen in bilateral costovertebral angles for renal artery bruits in a hypertensive patient suggestive of renal
artery stenosis.
*stenosis: Constriction or narrowing of a pasage or orifice (Tabers Medical Dictionary, 1989).
C. Listen over femoral areas for femoral artery bruits, in patients with lower extremity vascular insufficiency.
D. Venous Hum (rare) - epigastric/umbilical area.
A. Soft humming noises with both systolic/diastolic component.
B. Indicates increased collateral circulation between portal and venous systems as in hepatic cirrhosis.
E. Friction rubs (rare):
A. Right and left upper quandrants
B. Grating sound with respiratory movement
C. Indicates inflammation of peritoneal surface of an organ.
F. Succession splash:
A. Splashing sound indicative of air or fluid in body cavity with shaking individual: normal in s stomach.
Anonymous
Bowel sounds to assess bowel motility, and for the bruits of renal stenosis as a cause of HTN, and bruits over the aorta, iliac
and femoral arteries to detect arterial insufficiency in the legs.
Anonymous
Assessing bowel motility and abdominal complaints, as well as renal artery stenosis and vascular obstructions. Altered
bowel sounds occur in diarrhea, intestinal obstruction, paralytic ileus, and peritonitis (listen in the lower quadrants). Renal
artery stenosis causes bruits in the epigastrium and upper quadrants. Bruits over the aorta, the iliac arteries, and the femoral
arteries are also caused by stenosis. Infection of the liver and spleen will cause friction rubs that can be heard over these
areas.
Sung K, Swartz p.443-4
The patient is placed in the supine position and auscultation is performed by placing the diaphragm of the stethoscope
over the midabdomen.
Examine for Description
1. Bowel Normal bowel sounds occur approx. every 5-10 seconds and have a high-pitched sound. If after 2 minutes
Sounds no bowel sounds are heard, the statement “absent bowel sounds” may be made and suggest a paralytic
ileus that is due to diffuse peritoneal irritation. Also borborygmi associated with hyperperistalsis which is
common in early acute intestinal obstruction.
2. Obstructed A succussion splash may be detected in a distended abdomen as a result of the presence of gas and fluid
Viscus in an obstructed organ. The examiner applies the stethoscope over the patient’s abdomen while shaking
the patient from side to side. The presence of sloshing sound generally indicates distention of the stomach
or colon.
3. Abdominal Each quadrant should be evaluated for presence of bruits. Bruits may result from stenosis of the renal
Bruits artery or the abdominal aorta.
4. Peritoneal A peritoneal friction rub, like a pleural or pericardial rub, is a sound that indicates inflammation. During
Rubs respiratory motion, a friction rub may be heard in the right or left upper quadrants in the presence of hepatic
or splenic disorders.

10. Identify the locations on the abdomen for auscultating each of the following:
aorta, renal arteries, iliac arteries, and femoral arteries.

Zen Seeker

Anonymous
There is a photo on p. 362 of Bates which shows this much better than I can describe it.
Anonymous
Aorta = mid epigastric
Renal arteries = right upper quadrant and left upper quadrant
Iliac arteries = left lower quadrant and right lower quadrant
Femoral arteries = right lower quadrant and left lower quadrant
Sung K, Barkauskas p.395

11. Identify the purposes of percussion of the abdomen.

Anonymous Bates pg 362
Percussion helps you to assess the amount and distribution of gas in the abdomen and identify possible masses that are
solid or fluid filled.
Anonymous
 Helps to assess the amount and distribution of gas in the abdomen. HELPS TO id possible solid or fluid filled masses
and can be used to outline the borders of the liver and spleen.
Anonymous
To assess the amount and distribution of gas in the abdomen and to identify possible masses that are solid or fluid filled.
Dull areas might indicate ovarian tumor; distended bladder, large liver or spleen.
Sarra Vashchenko Swartz 444-Percussion is used to demonstrate the presence of gaseous distention and fluid or solid
masses. In the normal examination, generally only the size and location of the liver and spleen can be determined.
Some examiners prefer to palpate before percussion, especially if the patient complains of abdominal pain; either
approach is correct.
Tim Swartz, Ch. 16, pg. 444
Used to demonstrate the presence of gaseous distention and fluid or solid masses. Normally size and shape of the
liver and spleen can be determined.

12. Identify the normal span of liver dullness in both the right midclavicular line and the midsternal line.
Zen Seeker

Variation in liver span according to the vertical plane of examination. Since there is variability in where clinicians determine
the midclaviclar line to be, the inevitable consequence is that liver span may also vary even if multiple observers are perfectly
accurate in measuring it.

Percussive resonance varies with the thickness of interposed air filled lung tissue. The percussion note changes with
decreasing resonance caudally as less air filled lung tissue is interposed between the liver and ribs. However, the site of a
change from obvious resonance over the lung (point A) to less resonance (points B and C) may be difficult to judge.
Anonymous
In the right midclavicular line, liver dullness should be 6 to 12 cm. In the midsternal line liver dullness should be 4 to
8 cm. Bates pg 366
Anonymous
The liver span should be 6-12 cm. in the MCL.
The liver span should be 4-8 cm in the midsternal line.
Anonymous
Measure the vertical span of the liver dullness in the right midclavicular line by percussing upward starting below the
umbilicus. Ascertain the lower border of liver dullness in the midclavicular line. The upper border of liver dullness can be
percussed by starting at the right lung and moving down. After a line is developed measure in centimeters the distance
between the two points. Normal liver diameters are 4-8 cm in midsternal line and 6-12 cm in right midclavicular line.
Sarra Vashchenko Swartz 444- The upper border of the liver is percussed in the right midclavicular line, starting in the
midchest. As the chest is percussed downward, the resonant note of the chest becomes dull as the liver is
reached. As percussion continues still further, this dull note becomes tympanic because the percussion is now over
the colon. The upper and lower borders of the liver should be no more than 10cm apart.
Tim Swartz, Ch. 16, pg. 444, I don’t have bates but I bet it has a better description than swartz
The upper border of the liver is percussed in the right midclavicular line starting in the midchest (midsternal). As the
chest is percussed downward, the resonant note of the chest becomes dull as the liver is reached. As percussion continues
still further, this dull note becomes tympanic because the percussion is now over the colon. The upper and lower borders of
the liver should be no more than 10 cm apart.

13. Identify conditions, which may cause an increase or decrease in liver span by percussion.
Anonymous
Will increase when liver in enlarged, (Duh!)
Will decrease when liver is small, (double Duh!)
Will also be decreased when there is free air in the abdomen, as from a perforated hollow viscus. Bates pg 365
Anonymous
Inflammatory processes such as hepatitis or venous congestion (Rt. Heart failure) will cause the liver to be tender
and enlarged. A irregular hard, enlarged liver suggests malignancy. A smooth large non-tender liver may indicate
cirrhosis. COPD may cause the liver to be displaced downward by the lowered diaphragm.
The liver span may appear to decrease when the liver is smaller or when free air is present below the diaphragm, as
in a perforated bowel or stomach. Fulminant hepatitis may also cause a progressively smaller liver.
Anonymous
The span of liver dullness is increased when the liver is enlarged. Cirrhosis, hepatitis, venous congestion,malignancy. The
span of liver dullness is decreased when the liver is small. It may also be decreased when free air is present below the
diaphragm as from a perforated hollow viscus.. The span is usually greater in men and in tall people.
Tim Swartz Ch 16.
Upper and lower border should be no more than 10 cm apart.
Increased span can indicate hepatomegaly, inflammatory processes such as hepatitis or venous congestion (CHF)
will cause the liver to be tender and enlarged. Hard, enlarged liver suggests malignancy. A smooth large non-tender liver
indicates cirrhosis. COPD may cause the liver to be displaced downward by the lowered diaphragm.
The liver span may appear to decrease when the liver is smaller or when free air is present below the diaphragm, as
in a perforated bowel or stomach.

14. Identify conditions that may cause a false increase or decrease in estimated liver size by percussion.
Anonymous
Dullness of a right pleural effusion or consolidated lung may falsely increase the estimated size of the liver.
Gas in the colon may produce tympany in the right upper quadrant, obscure liver dullness, and falsely decrease the estimate
of liver size.
Anonymous
Rt. Plural effusion or consolidated lung may increase the estimate of liver span if it is adjacent to the dull percussion
of the liver.
Gas in the colon may produce tympani in the rt. upper quadrant falsely decreasing the estimate of liver span.
Anonymous
A consolidated lung or right pleural effusion adjacent to liver can falsely INCREASE the span. An obstructed and distended
gallbladder may form an oval mass below the edge of the liver and merging w/ it, dull to percussion.. Gas in the colon may
create tympany in the RUQ and falsely DECREASE the estimate of liver size.
Sarra Vashchenko Swartz 445
If ascites is present, the examiner can only speculate about the correct size of the liver. A more common cause of
overestimating liver size (false-positive measurement) is some form of chronic obstructive lung disease. This makes
percussion of the upper border of the liver difficult. Obesity can cause problems in both percussion and palpation. Distention
of the colon may obscure the lower liver dullness. This may result in understanding the size of the liver (false-negative
measurement).
Tim Swartz, Ch. 16, pg. 445
Ascites leads to a very difficult percussion exam and often the examiner has to speculate, can lead to false increase
or decrease in estimate.
Chronic obstructive lung disease leads to overestimation of size (false positive).
Obesity leads to difficulty and could be increased or decreased.
Distention of the colon obscures the lower liver dullness resulting in underestimation of size (false negative).

15. Identify COPD as a condition that may result in downward displacement of liver dullness.
Anonymous
The liver will be displaced downward because of the flattening of the diaphragm. The span, however, will remain normal.
Anonymous
Expansion of lung volume in COPD, emphysema can cause a permanent downward displacement of the diaphragm
which will push the liver lower into the abdominal cavity.
Anonymous
Liver dullness may be displaced downward by the low diaphragm of chronic obstructive lung disease. Span, however
remains normal
Tim - Swartz, ch 16, pg. 445
Makes upper border more difficult to percuss. Flatens out diaphragm and pushes down on the liver causing lower
dullness.

16. Describe the correct technique for percussion and palpation for:
a. splenic dullness.
b. liver dullness.
Zen Seeker
A. The Spleen
Percussion
1. Searching for the small area of dullness is seldom worthwhile unless you suspect splenomegaly.
2. Percuss in the lowest interspace in the left mid-axillary line. Have the patient take a deep breath and hold.
Repercuss the same area. Change from tympanic to dull indicates splenomegaly.
3. Percuss in several directions from resonance or tympanny toward forward estimates area of splenic
dullness to outline it’s edges.
Palpation
1. Seldom palpable in normal adults. Causes include COPD, and deep inspiratory descent of the diaphragm.
2. Support lower left rib cage with left hand while patient is supine and lift anteriorly on the rib cage.
3. Palpate upwards toward spleen with finger tips of right hand, starting well below left costal margin.
4. Have the patient take a deep breath.
5. Palpate for spleen as it descends.
6. A palpable spleen is almost always abnormal. Infectious mononucleosis may cause splenomegaly.
B. The Liver
Percussion
1. Percuss upward in right mid-clavicular line (MCL) from below umbilicus.
2. Ascertain lower liver border dullness.
3. Percuss from lung resonance downward on right MCL to ascertain upper margin of liver dullness.
4. Normally 6-12cm in right in right MCL.
Palpation
1. Place left hand posteriorly parallel to and supporting 11th & 12th ribs on right.
2. Place right hand in upper quandrant well below area of liver dullness.
3. Have the patient take deep breath and feel liver margin for smoothness, firm sharp edge, and tenderness.
4. An obstructed distended gall bladder may form an oval mass below the edge of the liver that merges with
the liver edge.
5. Start well below expected area of liver.
Anonymous Bates pp. 366
a. Splenic dullness.
Percuss the lowest interspace in the left anterior axillary line. This area is usually tympanitic. Then ask the patient to take a
deep breath, and percuss again. When spleen size is normal the percussion note usually remains tympanitic.
Palpation:With your left hand, reach over and around the patient to support and press forward the lower left rib cage and
adjacent soft tissue.With your right hand below the left costal margin, press in toward the spleen.Begin palpation low enough
so that you are below a possibly enlarged spleen.Pt. takes deep breath.Try to feel the tip or edge of spleen as it comes down
to meet your fingertips.Note any tenderness, assess the splenic contour and measure the distance btwn the spleen’s lowest
point and the left costal margin. Bates 369-370
b.Liver dullness.
Percussion:Right midclavicular line:start below umbilicus, in area of tympany.Lightly percuss up to liver.Locate the lower
border of liver dullness in the MCL.Then percuss from lung resonance down toward liver dullness.Be sure to displace breast
as necessary.Measure in cm distance btwn 2 points:vertical span of liver dullness.Percussion prob. Most accurate method of
measuring, but typically leads to underestimation.
Liver Palpation:Bimanual technique: left hand behind pt., parallel to/supporting 11th/12th ribs.Place R hand on R abdomen
lateral to rectal muscle, fingertips well below lower border of liver dullness.Press gently in & up.Try to feel liver edge as it
comes down to meet fingertips.If palpable at all, the edge of a normal liver is soft, sharp, regular w/ smooth surface.Normal
liver may be slightly tender.
Anonymous
Splenic percussion: Percuss the lowest interspace in the left anterior axillary line (see diagram in Bates 370). This area is
usually tympanic. Then ask the patient to take a deep breath, an d percuss again. When spleen size is normal, the
percussion note usually remains tympanic. A change in percussion note from tympany to dullness on inspiration suggests
splenic enlargement. Another way mentioned is to percuss the left lower anterior chest wall and the costal margin in an area
termed Traube's space. As you percuss along the routes suggested, note the lateral extent of tympany. See picture with
landmarks on page 369, Bates
Splenic palpation: This is the bimanual technique that we learned in class.
Liver percussion: Measure the vertical span of liver dullness in the right midclavicular line (MCL). Start at a level below the
umbilicus (in an area of tympany) lightly percuss upward toward the liver. Ascertain the lower border of the liver dullness in
the MCL Next determine the upper border of liver dullness in the MCL. Lightly percuss from lung resonance down toward
the liver dullness. Now measure in centimeters the distance between the two points. Please note that this sounds more
complex than what it is. If confused, look at the picture on page 365 Bates, and you will get the idea.
Liver Palpation: Again this is the bimanual technique that we have already learned. See page 366-367 for review.

17. Describe the purposes of performing light palpation of the abdomen; contrast this with the purpose of deep
palpation.
Zen Seeker
A. Light palpation
A. Gentle horizontal dipping motion with finger tips.
B. Have the patient supine with knees slightly flexed.
C. Identify muscular resistance and abdominal wall tenderness.
B. Deep palpation
A. Place one hand on top of the other. Press with outer hand and feel with inner hand.
B. Palpate tender areas last.
Anonymous
Light palpation helpful in identifying abdominal tenderness, muscular resistance and some superficial
organs/masses.Reassures/relaxes pt.(yeah right!)

Deep palpation normally required to delineate abdominal masses.Bates pp.

Anonymous
Light palpation: Feeling the abdomen gently is especially helpful in identifying abdominal tenderness, muscular resistance,
and some superficial organs and masses. It also serves to reassure and relax the patient. Bates 363.
Deep palpation: This is usually required to delineate abdominal masses.
Anonymous
Light palpation – feeling the abdomen gently is especially helpful in identifying abdominal tenderness, muscular
resistance, and some superficial organs and masses. It also serves to reassure and relax the patient.
Deep palpation – usually required to delineate abdominal masses.

18. Identify the significance of involuntary rigidity or spasm of the abdominal muscles.
Anonymous
It indicates peritoneal inflammation. Bates 363.
Anonymous
Rigidity (involuntary guarding or reflex spasm of abdominal muscles) is suggestive of underlying peritoneal inflammation,
as in pain referred to the point of maximum tenderness when palpating an adjacent quadrant. Can also be a sign of
perforated intra-abdominal viscus.

19. Identify the potential significance of abdominal pain on coughing or with light percussion. Bates (page 364)
Zen Seeker
Peritoneal irritation
a. Sharp, severe, intense pain
b. Localized to specific areas
c. Coughing increases the pain
Anonymous
Both are suggestive of peritoneal inflammation.
Anonymous
Abdominal pain on coughing or with light palpation suggest peritoneal inflammation, pain arising from the abdominal wall
or referred pain from the spine. A sharp increase in pain with coughing demonstrate rebound tenderness without the need for
palpation and release.

20. Identify the significance of rebound tenderness.

Anonymous
Suggests peritoneal inflammation. If tenderness is felt elsewhere than where you were trying to elicit rebound, that area
may be the real source of the problem. Bates 364.
Anonymous
“Rebound tenderness” (Deep palpation over the abdomen with sudden release), often regarded as the clinical criterion
standard of peritonitis. Peritoneal signs occur when the peritoneal lining is irritated, usually by infection or blood. False
positive rebound tenderness occurs in about one patient in four without peritonitis, perhaps because of non-specific startle
response. Because of this it may offer “no predictive value”.

21. Describe the correct technique for palpation of the liver, spleen, and kidneys. Identify the potential
significance of enlargement or tenderness of these organs.
Zen Seeker
Palpation of specific organs.
1. Liver
a. Place left hand posteriorly parallel to and supporting 11th & 12th ribs on right.
b. Place right hand in upper quandrant well below area of liver dullness.
c. Have the patient take deep breath and feel liver margin for smoothness, firm sharp edge, and tenderness.
d. An obstructed distended gall bladder may form an oval mass below the edge of the liver that merges with
the liver edge.
e. Start well below expected area of liver.
2. Spleen
a. Seldom palpable in normal adults. Causes include COPD, and deep inspiratory descent of the diaphragm.
b. Support lower left rib cage with left hand while patient is supine and lift anteriorly on the rib cage.
c. Palpate upwards toward spleen with finger tips of right hand, starting well below left costal margin.
d. Have the patient take a deep breath.
 e. Palpate for spleen as it descends.
f. A palpable spleen is almost always abnormal. Infectious mononucleosis may cause splenomegaly.
*Mononucleosis: Presence of an abnormally high number of mononuclear leukocytes in the blood (Tabers
Medical Dictionary, 1989).
3. Kidney
a. Place left hand posteriorly just below the right 12th rib. Lift upwards trying to displace the right kidney
anteriorly.
b. Palpate deeply with right hand on anterior abdominal wall.
c. Have the patient take a deep breath.
d. Feel for lower pole of kidney as it descends and try to capture it between your hands.
e. Have the patient release breath. Slowly release the kidney and feel it slide back into place.
f. Try the same on the left kidney, but is seldom palpable.
g. Costovertebral angle tenderness (CVA tenderness)
a. With patient seated upright, place palm of left hand over each costovertebral angle.
b. Strike back of left hand with ulnar surface of right fist.
c. Tenderness elicited suggest kidney infection such as pyelonephritis or perinephric abcess.
*pyelonephritis: Inflammation of kidney substance and pelvis.
*perinephric abcess: Absess formation in the peritoneal membrane surrounding the kidney
(Tabers Medical Dictionary, 1989).
Anonymous
Liver: Use the bimanual technique that we already have been taught. Tenderness or enlargement over the liver suggests
inflammation, or congestion as in hepatitis or congestive heart failure.
Spleen: Use the bimanual technique that we already have been taught. Enlargement and tenderness may be caused
by inflammation or infections such as viral hepatitis and mononeucleosis. Congestion such as cirrhosis, heart failure,
portal vein obstruction and splenic vein obstruction. Infiltrate such as Gaucher disease, amyloidism and diabetic
lipemia. Tumors or cysts. McCance 920.
Kidneys. For right kidney, place your left hand behind the patient just below and parallel to the 12th rib, with your finger tips
just reaching the costovertebral angle. Lift, trying to displace the kidney anteriorly. Place your right hand gently in the right
upper quadrant, lateral and parallel to the rectus muscle. Ask the patient to take a deep breath. At the peak of inspiration,
press your right hand deeply and firmly into the right upper quadrants, just below the costal margin, and try to "capture" the
kidney between your two hands. For palpation of left kidney. Use your right hand to lift from in back, and your left hand to
feel deep in the left upper quadrant. Proceed as before with right. See picture Bates 372. Causes of kidney enlargement
include hydronephrosis, cysts, and tumors. Bilateral enlargement suggests polycystic disease.
Deb B./Swartz,pg 449-452
Liver=place left hand posteriorly between pts rt. 12th rib and iliac crest, right hand placed in RUQ parallel and lateral to the
rectus muscles and below the area of the liver dullness. Pt instructed to take deep breath as examiner presses inward and
upward with rt. Hand and pulls upward with the left hand. Feel liver edge slip over the fingertips of rt. Hand as pt breaths.
Spleen=place left hand over pts chest and elevates pts left rib cage. Rt. Hand placed flat below left costal margin and
presses inward and upward toward the anterior axillary line. Pt instructed to take deep breath as you press inward with the
rt. Hand. Then repeat this technique with the pt lying on the right side. (first time they were lying supine)
Kidneys=Rt. Kidney—by deep palpation below rt. Costal margin. Stand at pts rt. Side and place left hand behind pts. Rt.
Flank, between costal margin and iliac crest. Right hand placed just below costal margin with tips of finger pointing to
examiner’s left. Feel lower pole of rt. Kidney during inspiration. Same procedure used for lt. kidney.
Greg R. Swartz, p. 449. Liver-(remember bi-manual palpation from class), Place your left hand posteriorly between the
patients 12th rib and the iliac crest. Place your right hand in the right upper quadrant parallel and lateral to the rectus
muscles. As the patient inhales deeply, depress your right hand inward and upward while pulling upward w/ the left. (See
Swartz fig. 16-23 or Bates p. 338-339, for good examples). Tenderness over the liver suggests; vascular congestion,
hepatitis, neoplasms, cirrhosis. Note there is another technique for palpating the liver on p. 449 in Swartz called “hooking”
and a method of checking for liver tenderness described Swartz on p. 450) Swartz p. 450-451=Spleen-(remember bi-manual
palpation from class), with the patient supine and you on the patients right side, place your left hand over the patient’s chest
and elevate the left rib cage. Place your right hand below the left costal margin and press inward and upward toward the
anterior axillary line (you should actually start this process near the umbilicus; the spleen enlarges toward the umbilicus).
Your left hand should pull up in an attempt to push the spleen forward. Repeat the exam with the patient lying on the right
side, this helps bring the spleen to a more favorable position for palpation. Tenderness over the spleen suggests;
hyperplasia, congestion, infection, or a tumor. Swartz p. 452=Kidney-Rarely palpable. But the procedure is as follows. For
the right kidney stand on patient’s right side, place your left hand behind patient’s right flank. Place your right hand just
below the costal margin with the tips of your fingers pointing to your left fingers, apply deep palpation. And for the left kidney
just switch sides. Note that the left kidney is often mistaken for the spleen. Bates p. 344-Tenderness from palpation could
indicate cysts, tumors, hydronephrosis. Bilat. tenderness could indicate polycystic disease. Swartz p. 452-453/Bates p. 344-
An exam technique that is more often used is to assess for tenderness by gently perusing them while the patient is seated.
With a closed fist gently strike the area over the costovertebral angle on each side. Tenderness indicates peylonephritis.

22. Describe the correct technique for palpation of the aorta. Identify the potential significance of a periumbilical
or upper abdominal mass with expansile pulsations in an older person.
Zen Seeker
Aorta
a. Press deeply in upper abdomen slightly lateral to midline on both sides.
b. Assess width of aorta pulsations. Normal is 2.5cm in width, not including abdominal wall thickness.
c. Prominent pulsations with lateral expansion suggest an abdominal aortic aneurysm.
Anonymous
Press firmly deep in the upper abdomen, slightly to the left of midline, and identify the aortic pulsation's. In patients over age
50, try to assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta
Bates 374. In an older person, a periumbilical or upper abdominal mass with expansile pulsation's suggests aortic
aneurysm.
Anonymous
Press firmly deep in the upper abdomen, slightly to the left of the mid-line, and identify the aortic pulsations. In persons over
age 50, try to assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the
aorta. In an older person, a periumbilical or upper abdominal mass with expansile pulsations suggests an aortic aneurysm.
(Bates, p374)
Deb B./Bates, pg.344
Assess the width of aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta
 Greg R. Bates p. 334. Aortic aneurysm.

23. Describe the correct technique for evaluating possible ascites through shifting dullness and fluid wave.
Anonymous
1. Test for shifting dullness – After mapping the borders of tympany and dullness, ask the patient to turn onto one side.
Percuss and mark the borders again. In a person without ascites, the borders between tympany and dullness usually
stay relatively constant. In ascites, dullness shifts to the more dependent side, while tympany shifts to the top.
2. Test for a fluid wave – Ask the patient or an assistant to press the edges of both hands firmly down the midline of the
abdomen. This pressure helps to stop the transmission of a wave through fat. While you tap one flank sharply with
your fingertips, feel on the opposite flank for an impulse transmitted through the fluid. Unfortunately, this sign is often
negative until ascities is obvious, and it is sometimes positive in people without ascites. An easily palpable impulse
suggests ascites.
Deb B./Bates,pg.346
Shifting dullness= after mapping borders of tympany and dullness, ask pt turn onto one side. Percuss and mark borders
again. In person without ascites, borders between tympany and dullness usually stay relatively constant.
Fluid wave= Ask pt to press edges of both hands firmly down the midline of the abdomen. This pressure helps to stop
transmission of a wave through fat. While you tap one flank sharply with your fingertips, feel on the opposite flank
for an impulse transmitted through the fluid. Unfortunately, this sign is often negative until ascites is obvious, and
sometimes positive in people without ascites.
Greg R. Bates p. 345-347. Shifting dullness-after mapping the abdominal border between tympany & dullness ask the
patient to turn to one side. Percuss and mark the borders again. In a person w/o ascites the borders between
tympany & dullness usually stay relatively constant. Fluid wave-ask patient or assistant to press the ulnar borders
of both hands firmly down the midline of the abdomen. This pressure helps stop the transmission of a wave through
fat. While you tap one flank sharply w/ your fingertips, feel on the opposite flank for an impulse transmitted through
the fluid. This sign is often (-) until ascites is obvious, & sometimes (+) in people w/o ascites.

23. Describe the correct technique and potential significance of each of the following maneuvers for evaluating
possible appendicitis:
local tenderness
involuntary rigidity
rectal and pelvic exam Bates 376
rebound tenderness
Rovsing's sign Bates 377
referred rebound tenderness Bates 377
psoas sign
obturator sign
cutaneous hyperesthesia
Zen Seeker

FIGURE 1A. The psoas sign. Pain on passive extension of FIGURE 2A. The obturator sign. Pain on passive internal rotation of
the right thigh. Patient lies on left side. Examiner extends the flexed thigh. Examiner moves lower leg laterally while applying
patient's right thigh while applying counter resistance to the resistance to the lateral side of the knee (asterisk) resulting in internal
right hip (asterisk). rotation of the femur.

FIGURE 1B. Anatomic basis for the psoas sign: inflamed

appendix is in a retroperitoneal location in contact with the
psoas muscle, which is stretched by this maneuver.

FIGURE 2B. Anatomic basis for the obturator sign: inflamed appendix
in the pelvis is in contact with the obturator internus muscle, which is
stretched by this maneuver.

Signs of peritoneal irritation in acute appendicitis

1. Progression of pain
a. Begins in umbilical area
b. Localizes in right lower quandrant
2. Guarding/muscular rigidity
a. Voluntary guarding by tightness of muscle against palpation.
 b. Involuntary resistance, progressive abdominal rigidity. Patient is unable to relax muscles. Body’s protective
function against pain.
3. Localized tenderness - usually in RLQ or right flank pain.
4. Rectal exam reveals right sided rectal tenderness. May indicate inflammatory process other than appendicitis.
5. Rebound tenderness
6. Rovsing’s sign (referred tenderness): tenderness/pain in RLQ during left sided pressure.
7. Referred rebound tenderness
8. Psoas sign: An increase in pain from passive extension of the right hip joint that stretches the iliopsoas muscle
(Tabers Medical Dictionary, 1989).
a. Place right hand above right knee of the patient.
b. Have the patient flex right knee against resistance.
c. Alternatively, have the patient turn to side, extend right leg at right hip.
d. Pain with maneuvers suggests irritation of Psoas muscle.
9. Obturator sign
a. Flex patients right thigh at hip with right knee bent.
b. Internally rotate the leg at the hip.
c. Pain elicited suggest irritation of obturator muscle.
10. Cutaneous Hyperesthesia: Increased sensitivity to sensory stimuli, such as pain or touch.
a. At a series of points down the abdominal wall, gently pick up skin folds between finger and thumb without
pinching the skin.
b. Localized pain elicited in the RLQ may accompany appendicitis.
Anonymous
Local tenderness: Localized tenderness anywhere in the right lower quadrant, even in the right flank, may indicate
appendicitis.
Involuntary rigidity: Early voluntary guarding may be replaced by involuntary muscular rigidity.
rectal and pelvic exam: These maneuvers may not help you to discriminate well between a normal and inflamed appendix,
but they may help to identify and inflamed appendix atypically located within the pelvic cavity. They may also suggest other
causes for abdominal pain.
rebound tenderness: Suggests peritoneal inflammation, as from appendicitis.
Rovsing's sign: Pain in the right lower quadrant during left sided pressure suggests appendicitis-a positive Rovsing's sign.
Referred rebound tenderness: Right lower quadrant pain on quick withdrawal.
Psoas sign: Place your hand just above the patients right knee and ask the patient to raise that thigh against your hand.
Alternatively, ask the patient to turn onto the left side. Then extend the patients right leg at the hip. Increased abdominal
pain on either maneuver constitutes positive psoas sign, suggesting irritation of the psoas muscle by an inflamed appendix.
Obturator sign: Flex the patients right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. Right
hypogastric pain constitutes a positive obturator sign.
Cutaneous hyperesthesia: At a series of points down the abdominal wall, gently pick up a fold of skin between your thumb
and index finger, without pinching it. Localized pain with this maneuver, in all or in part of the right lower quadrant, may
accompany appendicitis.
Anonymous
Local tenderness - Search carefully for an area of local tenderness. Localized tenderness anywhere in the right lower
quadrant, even in the right flank, may indicate appendicitis.
Involuntary rigidity – Feel for muscular rigidity. Early voluntary guarding may be replaced by involuntary muscular rigidity.
Rectal and pelvic exam – These maneuvers may not help you to discriminate well between a normal and an inflamed
appendix, but they may help to identify an inflamed appendix atypically located within the pelvic cavity. They may also
suggest other causes of the abdominal pain. Right-sided rectal tenderness may be caused by, for example, inflamed adnexa
or an inflamed seminal vesicle, as well as by an inflamed appendix.
Rebound tenderness – Rebound tenderness suggests peritoneal inflammation, as from appendicitis.
Rovsing’s sign and Referred rebound tenderness– Press deeply and evenly in the left lower quadrant. Then quickly
withdraw your fingers. Pain in the right lower quadrant during left-sided pressure suggests appendicitis (a positive Rovsing’s
sign.) So does right lower quadrant pain on quick withdrawal (referred rebound tenderness).
Psoas sign – Place your hand just above the patient’s right knee and ask the patient to raise that thigh against your hand.
Alternatively, ask the patient to turn onto the left side. Then extend the patient’s right leg at the hip. Flexion of the leg at the
hip makes the psoas muscle contract; extension stretches it. Increased abdominal pain on either maneuver constitutes a
positive psoas sign, suggesting irritation of the psoas muscle by an inflamed appendix.
Obturator sign – Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This
maneuver stretches the internal obturator muscle. Right hypogastric pain constitutes a positive obturator sign, suggesting
irritation of the obturator muscle by an inflamed appendix.
Cutaneous hyperesthesia – At a series of points down the abdominal wall, gently pick up a fold of skin between your thumb
and index finger, without pinching it. This maneuver should not normally be painful. Localized pain with this maneuver, in all
or part of the right lower quadrant, may accompany appendicitis.
Anonymous
Light palpation: Feeling the abdomen gently in all four quadrants is especially helpful in
identifying abdominal tenderness, muscular resistance, and some superficial organs and
masses. Deep palpation: usually required to delineate abdominal masses

a. Local tenderness: First, ask the patient to point to where the pain began and where it is now. Ask the patient to cough.
Determine whether and where pain results. The pain of an appendicitis classically begins near the umbilicus and
then shifts to the right lower quadrant (McBurney’s point) where coughing increases it. Carefully search for an area
of local tenderness (light palpation). Localized tenderness anywhere in the right lower quadrant, even in the
right flank, may indicate appendicitis.
b.Involuntary rigidity: Feel for muscular rigidity (light palpation). Early voluntary guarding (patient tensing abdominal
muscles voluntarily to prevent pain associated with deeper probing) may be replaced by involuntary muscular
rigidity (a state of constant tonicity) indicating peritoneal inflammation.
c. Rectal and pelvic exam: The techniques for these maneuvers have not been covered as of yet, however, the book
(Bates 376) suggests that a rectal exam with right-sided tenderness might be caused by appendicitis. Pelvic exam
of women may also illicit pain associated with appendicitis (again, a maneuver, as of yet, not covered).
d.Rebound tenderness: Press your fingers firmly and slowly into the area of abdomen (deep palpation) you are interested
in and then quickly remove them. Watch and listen to the patient for signs of pain. Ask the patient (1) to compare
which hurt more, then pressing or the letting go, and (2) to show you exactly where it hurt. Rebound tenderness
suggests peritoneal inflammation.
 e. Rovsing’s sign: Pain in the right lower quadrant during left-sided deep pressure. Suggestive of peritoneal inflammation
(specifically appendicitis).
f. Referred rebound tenderness: Pain in the right lower quadrant after quick withdrawal of deep left –sided pressure.
g. Psoas sign: Place your hand just above the patient’s right knee and ask the patient to raise that thigh against the
resistance of your hand. Alternately, ask the patient to turn onto the left side. Then extend the patient’s right leg at
the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it. Increased abdominal
pain on either maneuver constitute s a positive psoas sign, suggesting irritation of the psoas muscle by an
inflamed appendix.
h. Obturator sign: Flex the patient’s right thigh at the hip, with the knee bent, and rotate
the leg internally at the hip. This maneuver stretches the internal obturator muscle. Right hypogastric pain constitutes a
positive obturator sign, suggesting irritation obturator muscle by an inflamed appendix.
i. Cutaneous hyperesthgesia: At a series of points down the abdominal wall, gently pick up a fold of skin between your
thumb and index finger, without pinching it irritation. Localized pain with this maneuver, in all or part of the right
lower quadrant, may accompany appendicitis.
Deb B./Bates,pg. 347-348
Localized tenderness= anywhere in RLQ, even in right flank, may indicate appendicitis
Involuntary rigidity=constant tonicity, flexing of abdominal muscles
Rectal and pelvic exam=rt. Sided rectal tenderness may be caused by inflamed adnexa or an inflamed seminal vesicle, as
well as inflamed appendix
Rebound tenderness=suggests peritoneal inflammation, as from appendicitis
Rovsing’s sign=pain in rt. Lower quad. During left-sided pressure
Referred rebound tenderness=RLQ pain on quick withdrawal of pressure
Psoas sign= increased abdominal pain on either maneuver, (maneuver= place your hand just above pts. Rt. Knee and ask pt
to raise that thigh against your hand. Then extend pts. Rt. Leg at hip. Flexion of leg at hip makes psoas muscle contract.
Obturator sign= Flex pts. Rt thigh at hip, with knee bent, and rotate leg internally at hip, rt. Hypogastric pain constitutes pos.
obturator sign.
Cutaneous hyperesthesia= series of points down abdominal wall, gently pick up a fold of skin between your thumb and index
finger without pinching it. Localized pain with this maneuver in all or part of the rt. Lower quad. Is positive sign for
appendicitis
Greg R. Bates-
local tenderness p. 347-anywhere in the RLQ or right flank may indicate appendicitis.
involuntary rigidity p. 347-early voluntary guarding may be replaced by infoluntary muscle rigidity.
rectal and pelvic exam p. 347-right side rectal tenderness caused by inflamed adnexa or inflamed seminal vesicle, as well as
inflamed appendix.
rebound tenderness p. 348-suggests peritoneal inflammation, as from appendicitis.
Rovsing's sign p. 348-pain in RLQ during left side palpation suggests appendicitis.
referred rebound tenderness p. 348- RLQ pain on quick withdrawl of left side palpation suggests appendicitis.
psoas sign p. 348-abd. pain while p.t. contracts the psoas (p.t. supine) or stretching it (p.t. on side). Indicates irritation of
psoas from appendicitis.
obturator sign p. 348-pain while stretching the internal obturator muscle is (+) for an irritated obturator muscle from
appendicitis. To stretch the obturator muscle have p.t. lie supine with hip and knee flexed to 90 degrees, then
internally/medially rotate the hip.
cutaneous hyperesthesia p. 348-pain in RLQ while rolling small amount of skin between index finger & thumb may
accompany appendicitis

24. Describe the correct technique and potential significance of Murphy's sign.
Zen Seeker
Acute Cholecystitis: Inflammation of the gallbladder.
a. RUQ pain and tenderness
b. Murphy’s sign: When the inflamed gallbladder is palpated by pressing the fingers under the rib cage, deep
inspiration causes pain because the gallbladder is forced down to touch the fingers.
a. Hook fingers under costal margins on the right.
b. Have the patient take deep breath.
c. Sharp increase in tenderness with sudden stop in inspiration is positive.
d. Positive sign is indicative of gall bladder disease.
Anonymous
Used to assess acute cholecystitis. Hook your left thumb or the finger of your right hand under the costal margin at the point
where the lateral border of the rectus muscle intersects with the costal margin. Ask the patient to take a deep breath. Watch
the patient's breathing and note the degree of tenderness. Bates 377.
Anonymous
Hook your left thumbs or the fingers of your right hand under the costal margin at the
point where the lateral border of the rectus muscle intersects with the costal margin.
Alternately, if the liver is enlarged, hook your thumb or fingers under the liver edge at a comparable point below. Ask the
patient to take a deep breath. Watch the patient’s breathing and note the degree of tenderness. A sharp increase in
tenderness with a sudden stop in inspiration effort constitutes a positive Murphy’s sign of acute cholecystitis. Hepatic
tenderness may also increase with this maneuver, but is usually less well localized.
Deb B./Bates,pg 348
Hook left thumb or fingers of rt. Hand under costal margin at point where lateral border of the rectus muscle intersects with
the costal margin. Ask pt to take deep breath. Watch pts. Breathing and note tenderness. A sharp increase in
tenderness with a sudden stop in inspiratory effort is positive sign of acute cholecystitis.
Greg R. Bates p. 348. Hook left thumb or fingers of right hand under the ribs where the lateral border of the rectus muscle
meets the ribs. If pain w/ inspiration (+)Murphy’s sign for acute cholecystitis.

25. Describe how to distinguish an abdominal mass from a mass in the abdominal wall by palpation.
Zen Seeker
Intra-abdominal mass vs. abdominal wall mass
a. Have the patient tighten abdominal muscles wall.
b. Mass in abdominal wall remains palpable where as intra-abdominal mass will be obscured.
Anonymous
Ask the patient either to raise the head or shoulders or to strain down, thus tightening the abdominal muscles. Feel for the
mass again. A mass in the abdominal wall remains palpable, an intra-abdominal mass is obscured by muscular contraction.
Deb B./Bates, pg. 349
A mass in the abdominal wall remains palpable, an intra-abdominal mass is obscured by muscular contraction.
Greg R. Bates p. 349. Ask p.t. to raise head & shoulders or to strain down. Fell for mass, if palpable = abdominal wall
mass. If not palpable = intra-abdominal mass obscured by muscle contraction.

26. From the following tables describe the physical findings and causes associated the conditions described on
the tables in Bates pages 380-386(E-res)
Table 11-1 - Localized bulges in the abdominal wall
Table 11-2 - Protuberant abdomens
Table 11-3 - Sounds in the abdomen
Table 11-4 - Tender abdomens
Table 11-5 - Liver enlargement: apparent and real
EChing, Bates 3rd ed, p250-256
Abdominal hernias and bulges- almost always made more evident when the patient stands or raises his head and shoulders
from a supine position.
• Umbilical hernia
Physical findings: in young children, centrally located; in adults, partially above the umbilicus.
Cause: ??
• Incisional hernia
Physical findings: a defect in the abdominal muscles may develop after a surgical incision.
Cause: ??
• Diastasis recti (not a true hernia)
Physical findings: a separation of the two rectus abdominis muscles, the increased intra-abdominal pressure produced
when the pt raises his head and shoulders cuases a midline ridgelike bulge (no clinical consequence).
Cause: by pregnancy or obesity.
• Hernia of the Linea Alba
Physical findings: a small, often tender, midline nodule usually located in the epigastrium and best discovered with the pt
standing up. Its pain may mimic an ulcer. To find it, fun the pad of your index finger down the linea alba.
Cause: ??

Protuberant Abdomens
• Fat
Physical findings: abdominal wall is thick, umbilicus may appear sunken, percussion note is normal
Cause: fat is the most common cause and is associated with generalized obesity.

• Gas
Physical findings: gaseous distention is associated with a tympanitic percussion note.
Cause: gas
• Tumor (e.g., Ovarian)
Physical findings: a solid tumor, usually rising out of the pelvis, is dull to percussion. Air-filled bowel is displaced to
the periphery.
Cause: tumor
• Pregnancy:
Physical findings: the pregnant uterus pushes the umbilicus upward. Listen for the fetal heart.
Cause: pregnancy is a common cause of a pelvic “tumor”.

• Ascitic fluid
Physical findings: ascitic fluid seeks the lowest point in the abdomen, producing bulging flanks that are dull to
percussion. The umbilicus may protrude and be displaced downward when standing. Turn the pt on his side to
detect the shift in position of the fluid level (shifting dullness).
Cause: ascitic fluid??

Sounds in the Abdomen

• Bowel sounds
Physical findings: increased, as from diarrhea or early intestinal obstruction; decreased, then absent, as in
paralytic ileus and peritonitis.
Cause: In a dilated bowel, high-pitched tinkling sounds suggest intestinal fluid and air under tension. In
a intestinal obstruction, rushes of high-pitched sounds coinciding with an abdominal cramp.

• Systolic bruits
Physical findings: vascular sounds resembling cardiac murmurs. Do not be misled by a cardiac murmur radiating
to the abdomen!
Cause: suggest partial arterial obstruction or turbulent flow, as in an aneurysm.

• Venous hum (rare)

Physical findings: a soft humming noises with both systolic and diastolic components.
Cause: indicates increased collateral circulation between portal and systemic venous systems, as in hepatic
cirrhosis.

• Friction rubs (rare)

Physical findings: grating sounds with respiratory variation.
Cause: indicate inflammation of the peritoneal surface of an organ as from a liver tumor, gonococcal perihepatitis,
or splenic infarct. When a systolic bruit accompanies a hepatic friction rub, suspect carcinoma of the liver.

Tender abdomens
• Abdominal wall tenderness
Physical findings: occasionally tenderness originates from the abdominal wall, not within the abdominal cavity.
Distinguish these two sources by asking the pt to raise his head and shoulders or to strain down. Tenderness of a
superficial lesion persists on light palpation; tenderness of a deeper lesion decreases because of muscle guarding.
Cause:
 • Visceral tenderness
Physical findings: enlarged liver, normal aorta, normal cecum, normal or spastic signoid colon may be tender to
deep palpation. The discomfort is dull and there is no muscular rigidity or rebound tenderness.
Cause: normal (reassure pt)

• Tenderness from disease in the chest and pelvis

Acute pleurisy
Physical findings: unilateral or bilateral, upper or lower abdominal pain and tenderness.
Cause: secondary to acute inflammation of the pleurae.

• Acute salpingitis
Physical findings: frequently bilateral, the tenderness is usually maximal just ablove the inguinal ligaments.
Rebound tenderness and rigidity may be present. On pelvic exam, motion of the uterus causes pain.
Cause: acute salpingitis

• Tenderness of peritoneal inflammation

Physical finding: usually more severe than visceral tenderness. Muscular rigidity and rebound tenderness are
frequently but not necessarily present.

Causes:
Acute cholecystitis- signs are maximal in the right upper quadrant. Press your left thumb just under the right
costal margin and ask the pt to take a deep breath. A sharp increase in tenderness w/ a sudden stop in inspiratory
effort constitutes a positive Murphy’s sign of acute cholecycstitis.
Acute pancreatitis- epigastric tenderness and rebound are usually present but the abdominal wall may be soft
Acute appendicitis- right lower quadrant signs are typical but may be absent early in the course. Typical area
of tenderness is just below the middle of a line joining the umbilicus and the anterior superior iliac spine.
Acute diverticulitis- resembles a left-sided appendicitis.

Liver enlargement: apparent and real (estimates of liver size should be based upon full evaluation by both percussion and
palpation. A palpable liver edge does not necessarily indicate hepatomegaly.)

• Downward displacement of the liver by a low diaphragm

Physical findings: a common finding where the diaphragm is low. The liver edge may be readily palpable well
below the costal margin. Percussion reveals a low upper edge also, and the total span or height is normal.
Cause: emphysema.
• Normal variations in liver shape
Physical findings: in lanky build individuals, the liver tends to be somewhat elongated so the right lobe is easily
palpable as it projects downward toward the iliac crest (normal variation).
• Smooth nontender liver
Physical findings: an enlarged liver with a firm nontender edge
Cause: cirrhosis (liver is not always enlarged in this condition)
• Smooth tender liver
Physical findings: an enlarged liver with a smooth tender edge suggests inflammation
Cause: as in hepatitis, or venous congestion, as in right-sided heart failure.
• Irregular liver
Physical findings: an enlarged liver that is firm or hard and that presents an irregular edge or surface suggests
malignancy. There may be a single or multiple nodules. The liver may or may not be tender.
Cause: malignancy
A.T. Bates. p. 360. Localized bulges in the abdominal wall.
Umbilical hernia- Defect in the umbilical ring common in infants and my resolve. Also, in adults.
Incisional hernia- protudes through an operable scar. Note length and width of protrusion compared to opening.
Smaller openings pose greater risk for complications.
Epigastric hernia- Small Midline hernia, defect in the linea alba, between xiphoid and umbilicus.
Diastasis recti- separation of the rectus abdomenus muscle, contents bulge from to form a midline ridge. Repeated
pregnancies, obesity, and chronic lung disease predispose to it. No clinical consequences.
Lipoma- common fatty benign tumor, located SQ. soft and lobulated. Tumor can slip out from under during palpation.
A.T. Bates p. 360. Protuberant abdomens
Fat- Most common, associated with general obesity, normal percussion. May have to lift to assess the skin and for
hernias.
Gas- localized or general, mild distention greater in the colon than the SI.
Tumor- Dull to percussion, ovarian tumors and uterine myomata. May be mistaken with a marketedly distended
bladder.
Pregnancy-
Ascitic fluid- the fluid seeks the lowest part in the abdomen, dull to persussion. Umbilicus may protrude. Turn patient
to one side to detect a fluid shift.
A.T. Bates p. 362. Sounds in the abdomen.
Bowel sounds- increased in diarrhea, decreased in peritonitis, must listen for 2 min. to declare absent.
Bruits- Hepatic bruits suggests tumor or alcoholic hepatitis.
Venous hum- Rare, Indicated increased collateral circulation.
Friction rubs- rare, indicate inflammation of the peritoneal surface. When a bruits accompanies a friction rub suspect
liver carcinoma.
A.T. Bates p. 363 Tender abdomens
Abdominal wall tenderness- Superficial tenderness persists when pt. lifts head and shoulders. Deep tenderness- the
pain decreases.
Visceral tenderness- Tenderness to palpate liver, aorta, cecum and spastic colon sigmoid colon.
Acute pleurisy- pleural inflammation, may mimic appendicitis or cholecystitiis. Rebound tenderness and rigidity less
common.
Acute sallpingitis- frequently bilateral, just above inguinal ligaments, rebound tenderness, on pelvic motion of the
uterus causes pain.
A.T. Bates p. 365.Liver enlargement: apparent and real
 Downward displacement by a low diaphragm- common in emphysema. Percussion reveals a low upper edge also.
And vertical span is normal.
Normal variation in liver shape-those with a lanky build may elongated livers, Riedel’s lobe variation in shape not
volume.
Smooth large non-tender-possibly cirrhosis, not always enlarged.
Smooth large tender- suggest inflammation, hepatitis, venous congestion, right sided heart failure.
Large irregular- suggest malignancy, one or more nodules, may or may not be tender.

27. Given a patient be able to perform a complete and thorough GI examination and identify and be able to
communicate any abnormalities found.