Você está na página 1de 181

Abdominal Examination

General principles of exam

Abdominal Examination
The History and Physical in
Perspective
70% of diagnoses can be made based on
history alone.
90% of diagnoses can be made based on
history and physical exam.
Expensive tests often confirm what is
found during the history and physical.
Equipment for physical examination
Required Optional
Stethoscope Gloves
Tongue blades Gauze pads
Penlight Lubricant gel
Tape measure Nasal speculum
Sphygmomanometer Turning fork: 128 Hz,512Hz
Reflex hammer Pocket visual acuity
Safety pins card
Oto-ophthalmoscope
Important aspects of physical
examination----physician
Elegant appearance
Decent manner
Kind attitude
Highly responsibility
Good medical
morals
Important aspects of physical
examination---physician
Wash your hands,
preferably while the
patient is watching

Washing with soap


and water is an
effective way to
reduce the
transmission of
disease
How to perform the physical
examination?

Exposing only the


area that are being
examined
Offer a chaperone for
both sexes.
Explain what you're
going to do
Sequential
Important aspects of physical
examination
The examiner should
continue speaking to
the patient

Showing care to his


disease and answer to
patients questions

It can not only release


patients nerviness, but
also help to establish
the good physician-
patient relationship
Gloves should be worn when..
Examining any
individual with
exudative lesions or
weeping dermatitis
When handling
blood-soiled or body
fluid-soiled sheets
or clothing
General principles of exam

Good light
Relaxed
patient
Full exposure
of abdomen
General principles of exam
Have the patient
empty their bladder
before examination
Have the patient lie in
a comfortable, flat,
supine position
Have them keep their
arms at their sides or
folded on the chest
General principles of exam
Before the exam, ask
the patient to identify
painful areas so that
you can examine
those areas last
During the exam pay
attention to their facial
expression to assess
for sign of discomfort
General principles of exam
Use warm hand,
warm stethoscope,
and have short finger
nails
Approach the patient
slowly and
deliberately
explaining what you
will be doing
General principles of exam

Stand right side of the


bed
Exam with right hand
Head just a little
elevated
Ask the patient to
keep the mouth
partially open and
breathe gently
General principles of exam

If muscles remain
tense, patient may
be asked to rest
feet on table with
hips and knees
flexed
Other helpful points on examination

Take a spare bed


sheet and drape it
over their lower body
such that it just
covers the upper
edge of their
underwear
General principles of exam
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.
Watch the patients
face for discomfort.
Think
Anatomically
Think Anatomically
When looking,
listening, feeling and
percussing imagine
what organs live in
the area that you are
examining.
Right Upper Quadrant (RUQ)
liver, gallbladder,
duodenum,
right kidney
and hepatic
flexure of colon
Right Lower Quadrant (RLQ)
Cecum,
appendix (in
case of female,
right ovary &
tube)
Left Lower Quadrant (LLQ)

Sigmoid
colon (in case
of female, left
ovary & tube)
Left Upper Quadrant (LUQ)
Stomach,
spleen, left
kidney, pancreas
(tail), splenic
flexure of colon
Epigastric Area
Stomach,
pancreas
(head and
body), aorta
Landmarks of the abdominal wall,

Costal margin,
umbilicus, iliac crest,
anterior superior iliac
spine, symphysis
pubis, pubic tubercle,
inguinal ligament,
rectus abdominis
muscle, xiphoid
process.
Physical Examination of the
Abdomen
Inspection
Auscultation
Percussion
Palpation
Special Tests
Inspection

Abdominal examination
Appearance of the abdomen

Is Aortic pulsation?
Is it flat or Scaphoid
(Normally)?
Distended?
If enlarged, does this
appear symmetric?
With bulging or
moving?
Symmetrical in shape

slightly full but not distended in older age


Scaphoid or flat in young group due to poor muscle tone or in
patients of normal weight subjects who are mildly overweight
Appreciation of abdominal contours

Standing at the foot of


the table and looking up
towards the patient's
head.
Lower yourself until the
anterior abdominal
wall and ask the patient
to breathe normally while
you are doing so.
Appearance of the abdomen

Global
abdominal
enlargement is
usually caused
by air, fluid, or
fat.
Appearance of the abdomen

Localized
enlargement
probably distend
GB space
occupying lesion,
hepatomegaly.
An aortic aneurysm
Palpable mass
Patient feeling of
pulsation
On rare occasions, a
lump can be visible.
An aortic aneurysm
1 in 10 men over 65
may have some
enlargement of the
abdominal aorta.
About 1 in 100 will
have a large
aneurysm requiring
surgery.
Appearance of the abdomen
(Skin)

Abnormal venous
patterns
Abnormal
discoloration
Umbilicus is sunken
Striae
Stretch marks are a
light silver hue.
Pregnancy and obese
individuals
Cushings syndrome
(more purple or pink).
Appearance of the abdomen
(Skin)
Tattoos
Scars can be drawn
on schematic
diagrams of the
abdomen (a picture is
worth a thousand
words).
Cullens sign
Ecchymosis
periumbilically.
(intraperitoneal
hemorrhage
ruptured ectopic
pregnancy,
hemorrhagic
pancreatitis..)
Grey-Turners sign
Ecchymosis of
flanks.
(retroperitoneal
hemorrhage
such as
hemorrhagic
pancreatitis)
SVC = superior vena cava IVC = inferior vena cava
Upward flow direction indicates IVC obstruction
Outward flow pattern from umbilicus in all directions ? Portal HTN
Evaluate venous return states

Place index finger


side by side over a
vein and press
laterally, milking vein.
Release one finger
and time refill, repeat
with other finger.
Venous return is in
direction of faster
filling.
Appearance of the abdomen
Areas which
become more
pronounced when
the patient
valsalvas are
often associated
with ventral
hernias
Visible Pulsations
More conspicuous in the In those with an aortic
thin than in the fat aneurysm and tortuous
Greater in the old than in aorta
the young. In those who have a
Increased in mass joining the aorta to
thyrotoxicosis, the anterior abdominal
hypertension, or aortic wall.
regurgitation)
Visible gastric Peristalsis Visible intestinal Peristalsis

Gastric peristalsis is Intestinal peristalsis in


commonly seen in partial and chronic
neonates with intestinal obstruction
congenital Colonic obstruction is
hypertrophic pyloric usually not manifest
stenosis as visible peristalsis
Appearance of the abdomen
Patient's movement

Patients with kidney


stones will frequently
writhe on the
examination table,
unable to find a
comfortable
position
Appearance of the abdomen
Patient's movement

Patients with
peritonitis prefer to lie
very still as any
motion causes further
peritoneal irritation
and pain.
Auscultation

Abdominal examination
Auscultation

Bowel sounds
Vascular sounds (bruits)
Friction Rubs
Auscultation for bowel sounds

It is performed before percussion or


palpation
Auscultation for bowel sounds
Normal sounds are
due to peristaltic
activity.
Peristalsis: A
pregressice wavelike
movement that occurs
involuntarily in hollow
tubes of the body.
Auscultation for bowel sounds

Compared to the
cardiac and
pulmonary exams,
auscultation of the
abdomen has a
relatively minor role.
Auscultation for bowel sounds

Bowel sounds lend


supporting
information to other
findings but are not
pathognomonic
for any particular
process.
Auscultation

1.Diaphragm of
stethoscope
used
2.Skin
depressed to
approximately 1
cm
Auscultation

3.Listening in one
spot is usually
sufficient
4.Listening for 15-20
or 30-60 seconds
5.Bowel sounds cannot
be said to be absent
unless they are not heard
after listening for 3-5
minutes.
Three things about bowel
sound
Are bowel sounds
present?
If present, are they
frequent or sparse
(i.e.quantity)?
What is the nature of
the sounds
(i.e.quality)?
Bowel sound decrease

Inflammatory
processes of the
serosa
After abdominal
surgery
In response to
narcotic analgesics or
anesthesia.
Auscultation for bowel sounds

Inflammation of the
intestinal mucosa
will cause
hyperactive bowel
sounds.
Auscultation for bowel sounds
Processes which
lead to intestinal
obstruction initially
cause frequent
bowel sounds,
referred to as
"rushes."
Auscultation for bowel
sounds
Processes which lead
to intestinal
obstruction initially
cause frequent bowel
sounds, referred to as
"rushes."
Auscultation for bowel sounds
Rushes" means
as the intestines
trying to force
their contents
through a tight
opening.
Auscultation for bowel
sounds
Rushes" is followed
by decreased sound,
called "tinkles," and
then silence.
Auscultation for bowel
sounds
After silence the
appearance of bowel
sounds marks the
return of intestinal
sounds activity, an
important phase of
the patient's recovery.
Splash Sign

Splashing sound
indicative of air or
fluid in body cavity
with shaking
individual: normal in s
stomach.
Auscultation for bowel sounds
Bowel sounds,
then, must be
interpreted within
the context of the
particular clinical
situation.
Bruits

Bruits confined
to systole do not
necessarily
indicate disease.
Auscultation for vascular sounds
(bruits)
Aortic (midline between
umbilicus and xiphoid
Renal (two inches
superior to and two
inches lateral to
umbilicus)
Common iliac (midway
between umbilicus
and midpoint of
inguinal ligament)
Auscultation for vascular sounds
(bruits)

Presence of a bruit
on the renal artery
would lend
supporting
evidence for the
existence of renal
artery stenosis.
Auscultation for vascular sounds
(bruits)
When listening for
bruits, you will need
to press down quite
firmly as the renal
arteries are
retroperitoneal
structures.
Venous Hum (rare)
Epigastric/umbilical
area.
Soft humming noises
in systolic/diastolic
component.
Indicates collateral
between portal and
venous systems as in
hepatic cirrhosis.
Rubs Rubs-Rubs

Liver
Spleen
Cardiac
Pulmonary
Friction rubs (rare)

Right and left upper


quandrants
Grating sound with
respiratory movement
Indicates
inflammation of the
capsule of the liver or
spleen (infection or
infarction).
Percussion

Abdominal examination
Percussion

Technique
Liver
Spleen
Percussion (technique)

DIP joint of third


finger (pleximeter)
pressed firmly on the
abdomen remainder
of hand not touching
the abdomen
Percussion (technique)
Striking hand
should move
only at the wrist,
with only little
more than force
of gravity
Percussion (technique)
Middle finger of
striking hand
(plexor) should
knock the
pleximeter firmly,
with a strong
note
There are two basic sounds with
Percussion
Tympanitic
(drum-like)
sounds
produced by
percussing over
air filled
structures.
There are two basic sounds with
Percussion

Dull sounds that


occur when a solid
structure (e.g. liver)
or fluid (e.g. ascites)
lies beneath the
region being
examined.
Examination of Liver (Percussion)

Midclavicular line
is noted
Second
intercostal space
is noted
The two solid organs are
percussable in the normal patient
Liver: will be entirely
covered by the ribs.
Occasionally, an edge
may protrude 1-2
centimeter below the
costal margin.
Spleen: The spleen is
smaller and is entirely
protected by the ribs.
To determine the size of the liver
Measure the liver
span by percussing
hepatic dullness from
above (lung) and
below (bowel). A
normal liver span is 6
to 12 cm in the
midclavicular line.
To determine the size of the liver
Start just below the
right breast in a line
with the middle of
the clavicle.
Percussion in this
area should
produce a relatively
resonant note.
To determine the size of the liver
Move your hand
down a few
centimeters than
you will be over
the liver, which
will produce a
duller sounding
tone.
To determine the size of the liver
Continue
downward until
the sound
changes once
again. At this
point, you will
have reached the
inferior margin of
the liver.
Examination of Liver (Percussion)
Upper margin is
noted by first dull
percussion note
Lower margin is
noted by first
tympanitic note
To determine the size of the
liver
The resonant tone produced by
percussion over the anterior chest
wall will be somewhat less drum like
then that generated over the
intestines. While they are both
caused by tapping over air filled
structures, the ribs and pectoralis
muscle tend to dampen the sound.
Examination of Spleen
(Percussion)
Percussion at Castells Spot
Castells Spot identified
Left anterior axillary line identified
Left lower costal margin identified
Percussion at Castells Spot while patient
inhales and exhales deeply

Dull tone indicates


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

Abdominal examination
Abdominal Palpation

Technique Spleen tip


Light Kidneys
Deep Aorta
Liver edge Masses
Abdominal palpation
To palpate four
quadrants
superficially
from LLQ
counterclockwise
Light Palpation
Light Palpation
First warm your
hands by rubbing
them together before
placing them on the
patient.
Abdominal wall
depressed
approximately 1 cm
Abdominal palpation
Use pads of three
fingers of one hand
and a light, gentle,
dipping maneuver to
examine abdomen
Palpation (light)
Any areas of pain or
tenderness are
reserved for
evaluation at the end
of the exam
Light Palpation
Mostly looking for
areas of tenderness
Tenderness is a
physical exam finding
a reflex occurs
(muscle splinting,
wide eyes, moaning,
teeth gritting).
Palpation
Light palpation assesses
Muscle tone
Cutaneous
hypersensitivity
(suggests peritoneal
irritation)
Palpation
Light palpation assesses
Presence of
superficial
(intramural) masses is
more prominent if
patient raises their
head ,Intra-abdominal
mass is less
prominent if patient
raises their head
Deep Palpation
Palpation (deep)

Entire palm
Either one- or
two handed
technique is
acceptable
Deep Palpation
Use palmar surface of
fingers of one hand
(greatest number of
fingers) and a deep,
firm, gentle maneuver
to examine abdomen
Palpation

Palpate deeply with


finger pads (do not
dig in with finger
tips)
Deep Palpation
Palpate tender areas
last
Try to identify
abdominal masses or
areas of deep
tenderness
Two handed technique
When deep
palpation is difficult,
examiner may
want to use left
hand placed over
right hand to help
exert pressure
Palpation (deep)

Push as deeply as
patient will allow
without significant
discomfort
Normal structure that may be
palpable
Sigmoid colon Distended bladder
Liver Gravid and non-
Kidney gravid uterus
Abdominal aorta Xyphoid process
Iliac artery spleen
Abdominal mass
Intra abdominal
masses or
enlargements of the
liver, gallbladder or
spleen
Abdominal wall mass
Intra abdominal masses or enlargements of
the liver, gallbladder or spleen
They will shift down
with inspiration and
back with expiration.
(not true of masses
within the abdominal
wall or retroperitoneal
structures).
Abdominal wall mass
It will become more
evident and palpable
when patient flexes
neck as this contracts
rectus muscles.
Paraumbilical node
Abdominal pain and
Tenderness
Type of abdominal pain

Visceral pain Somatic pain


Visceral pain
This is pain that
arises from an
organic lesion or
functional disturbance
within an abdominal
viscus (dull, poorly
localized, and difficult
for the patient to
characterize).
Somatic pain
Painful lesion of the
skin
Sharp, bright, and
well localized
Indicates
involvement of
parietal peritoneum
or the abdominal
wall itself
Tenderness
If there is tenderness
determine the point of
maximum tenderness
and its distribution
Abdominal muscle spasm
Voluntary guarding Involuntary guarding
Tensing abdominal Muscular spasm or
muscles due to rigidity due to
patient anxiety, peritoneal
ticklishness, or inflammation
toprevent palpation to May be localized
a painful area (early appendicitis )or
diffuse (perforated
bowel)
Board-like rigidity
If abdominal wall is
palpated as obviously
tense, even as rigid
as a board, board-like
rigidity is so called. Is
caused by the spasm
of abdominal muscle
due to peritoneal
irritation.
Differential diagnosis of abdominal
pain
Spine pain
Abdominal wall
pain( differentiated by
having the patient
tense his abdominal
muscles, by forcefully
elevating his head
while keeping his
shoulders flat on the
table)
Liver palpation
Liver palpation
(Standard Method)
Start in the RUQ,10
centimeters below the
rib margin in the mid-
clavicular line
Place left hand
posteriorly parallel to
and supporting 11th &
12th ribs on right.
Standard Method Liver palpation

Ask the patient to


take a deep breath.
You may feel the
edge of the liver press
against your fingers.
Liver palpation
(Standard Method)

Palpating hand is
held steady while
patient inhales
Liver palpation
(Standard Method)
Palpating hand is
lifted and moved
while the patient
breathes out
Liver palpation
Another method of
palpating the liver
uses the radial border
of the index finger. In
this method the
anterior hand is
placed flat on the
anterior abdominal
wall with fingers
parallel to the costal
margin
Alternate Method Liver palpation

Is useful when the


patient is obese or
when the examiner
is small compared
to the patient.
Alternate Method Liver palpation

Stand by the patient's


chest.
"Hook" your fingers
just below the costal
margin and press
firmly.
Hepatomegaly
More than 1cm below
the costal margin
An exception is a
congenitally large
right lobe of the liver
Severe, chronic
emphysema
Pulsation transmitted from aorta Tricuspid valve insufficiency
Hepatojugular reflux sign
If you press the liver,
you will find the
dilated jugular vein
becomes more
bulged or distended,
as from the
enlargement of liver
passive congestion
resulted from right
failure.
Ballotable sign
Spleen palpation
Spleen palpation

Seldom palpable in
normal adults.
Causes include
COPD, and deep
inspiratory descent of
the diaphragm.
Spleen palpation

Support lower left rib


cage with left hand
while patient is supine
and lift anteriorly on
the rib cage.
Spleen palpation

Palpate upwards
toward spleen with
finger tips of right
hand, starting below
left costal margin.
Have the patient take
a deep breath.
Examination of Spleen
(Palpation)

Deep technique used


Starting point is RLQ,
proceeding to LUQ
Kidney palpation
Kidney palpation
Place left hand
posteriorly just below
the right 12th rib. Lift
upwards.
Palpate deeply with
right hand on anterior
abdominal wall.
Examination of Kidney
Patient take a deep
breath.
Feel lower pole of
kidney and try to
capture it between
your hands.
Examination of Kidney

Right kidney may be felt to slip between hands


during exhalation
Palpation of the Aorta
Examination of Aorta

Flat palm placed


over the the
epigastrium to
locate pulse
Examination of Aorta
Press down deeply in
the midline above the
umbilicus.
The aortic pulsation is
easily felt on most
individuals.
Examination of Aorta

Hands then oriented


vertically on either
side of midline with
distal fingers at level
of pulsation; equal
pressure applied until
pulsation is palpated

A well defined, pulsatile mass, greater than


cm across, suggests an aortic aneurysm.
Examination of Aorta

Lateral width of pulsation is determined by


space between index fingers
Special exam

Abdominal examination
Special exam
Murphys Sign Re bound
McBurneys Tenderness
Point Costovertebral
Rovsings Sign tenderness
Psoas Sign Shifting
Obturator Dullness
Sign
Fluid wave
Murphys Sign (acute cholecystitis)

Examiners hand is at
middle inferior border
of liver.
Patient is asked to
take deep inspiration.
If positive patient will
experience pain and
will stop short of full
inspiration
Hepatitis, subdiaphragmatic
abscess Cholecystitis
McBurneys Point

Localized tenderness
Just below midpoint
of line between right
anterior iliac crest and
umbilicus.
Heel strike, riding
over bumps in road
while driving,
coughing, will
produce pain.
McBurneys Point (Common Causes)
Appendicitis
Incarcerated or
strangulated hernia
Ovarian torsion (twisted
Fallopian tube)
Pelvic inflammatory
disease
Abdominal abscess
Hepatitis
Diverticular disease
Meckel''s diverticulum
Rovsings Sign

Patient will
experience right lower
quadrant pain (in
region of McBurneys
Point) when left lower
quadrant is palpated.
Non-Classical Appendicitis

Iliopsoas Sign

Obturator Sign
Iliopsoas Sign

Patient can lay on side and extend leg at the hip


or have patient lay on back and try to flex hip
against the resistance of examiners hand on
thigh. If patient has an inflamed retrocecal
appendix, this will produce pain.
Iliopsoas Sign
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.
Obturator Sign

Internally rotate right leg at the hip with the knee


at 90 degrees of flexion. Will produce pain if
Obturator Sign
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.
Rebound Tenderness
(For peritoneal irritation)

Warn the patient what


you are about to do.
Press deeply on the
abdomen with your hand.
After a moment, quickly
release pressure.
If it hurts more when you
release, the patient has
rebound tenderness. [4]
Cost vertebral Tenderness
(Often with renal disease)
Use the heel of your
closed fist to strike
the patient firmly
over the
costovertebral
angles.
Compare the left
and right sides.
Warn the patient Patient sit up on the exam table
Shifting Dullness
(For peritoneal fluid)

Percuss from anterior


abdomen laterally to
outline areas of
dullness noted
Examination for Shifting
Dullness
Patient rolled slightly
toward the examined
side; movement of the
dull point medially is
described as shifting
dullness and
suggests ascites
Shifting Dullness
Fluid wave