Abdominal Exam

History

  • Symptoms: pain (mucosal irritation, smooth muscle spasm, peritoneal irritation, capsular swelling, direct nerve stimulation), nausea, vomiting, change in BM, rectal bleeding (BRBPR or hematochezia), jaundice, abdominal distention, mass, pruritis
  • PMHx

Inspection

  • General appearance – writhing (biliary colic), still (peritonitis), knees drawn up (relax abdominal muscles and reduce intra-abdominal pressure)
    • Jaundice, anemia, cyanosis, clubbing, oedema, lymphadenopathy
  • Respiratory rate – increased if peritonitis, intra-abdominal hemorrhage, intestinal obstruction
  • Skin and sclera changes – colour, spider angiomas (alcoholic cirrhosis, pregnancy, collagen vascular disorder), ulcers (pyoderma gangrenosum – assoc’d with IBD)
  • Hands – wasting, nails (half and half in cirrhosis)
  • Facies – eyes sunken, temporal wasting (poor nutrition), melanin deposition around oral cavity (Peutz-Jeghers), telangiectasias, Cushing’s facial plethora (moon facies)
  • Abdomen – contour (scaphoid, protuberant), asymmetry, masses, distention, visible peristaltic waves, striae, scars, ecchymoses (Grey Turner’s, Cullen’s – hemoperitoneum), visible vessels (caput medusae)

Auscultation

  • Pt in supine position: normal sounds q5-10seconds, high-pitched
  • Nothing after 2 minutes – absent bowel sounds (paralytic ileus)
  • Low-pitched rumbling – borborygmi (hyperperistalsis – early acute intestinal obstruction)
  • Succussion splash – gas and fluid in obstructed organ (apply stethoscope and shake pt)
  • Bruits – renal, aorta, hepatic
  • Peritoneal rubs – inflammation



 

Percussion

  • Abdomen – tympany (presence of gas within stomach, bowel), suprapublic area dull if uterus enlarged or bladder distended
  • Liver – midclavicular line normally 9 – 11cm
  • Spleen – Traube’s space (6th rib superiorly, left anterior axillary line laterally and costal margin inferiorly) loss of tympany
    • Castell’s method – percuss in lowest interspace in left anterior axillary line during inspiration and expiration – should remain resonant
  • Ascites – Shifting dullness, fluid wave, bulging flanks

Palpation

  • Light – tenderness, muscular spasm, rigidity (diffuse or localized – due to peritoneal irritation), hyperesthesia
  • Deep – organ size, guarding, rebound tenderness
  • Liver – normal edge is firm, regular ridge, with smooth surface; hooking method; scratch test; liver tenderness (hand on RUQ, strike with fist gently); Murphy’s sign (pain on inspiration)
  • Spleen – left hand over pt’s chest and elevates rib cage, right hand flat below left costal margin and presses inward and upward – pt may lie on right side
  • Kidney – CVA tenderness

Special tests:

  • Rectal exam
  • Iliopsoas – pt lies on unaffected side and extends other leg at hip against resistance – psoas sign
  • Obturator – pt on back and examiner flexes the thigh at the hip with knee bent and rotates leg internally and externally at hip

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