Presentation on theme: "Abdominal Physical Examination"— Presentation transcript:
1 Abdominal Physical Examination Joel Niznick MD FRCPC
2 Acknowledgements Adapted from Public Domain Web Slide-sets by: Jim Pierce, MDLuke Palmisano, MS IIIKamilee Christenson, MS IIH.A.Soleimani MD
3 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.Assess the acuity of the patient to focus your differential diagnosis
4 General principles of exam Stand right side of the bedExam with right handHead just a little elevatedAsk the patient to keep the mouth partially open and breathe gently
5 General principles of exam If muscles remain tense, patient may be asked to rest feet on table with hips and knees flexed
6 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
7 General principles of exam If the patient is ticklish or frightenedInitially use the patients hand under yours as you palpateWhen patient calms then use your hands to palpate.Watch the patient’s face for discomfort.1
28 BruitBruits confined to systole do not necessarily indicate disease.
29 Auscultation for vascular bruits Aortic (midline between umbilicus and xiphoidRenal (two inches superior to and two inches lateral to umbilicus)Common iliac (midway between umbilicus and midpoint of inguinal ligament)
30 Auscultation for vascular bruits When listening for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal structures.
32 Rubs –Rubs-Rubs Liver Spleen Cardiac Pulmonary Right and left upper quandrantsGrating sound with respiratory movementIndicates inflammation of the capsule of the liver or spleen (infection or infarction).
33 Venous Hum (rare) Epigastric/umbilical area. Soft humming noises in systolic/diastolic component.Indicates collateral between portal and venous systems as in hepatic cirrhosis.
34 Percussion versus Palpation Light Palpation assesses:Masses and Tenderness in the WallDeep Palpation assesses:Masses and Tenderness in the CavityPercussion assesses:Location of organsLocation of massesDeep tenderness
36 Light Palpation Inquire as to location of tenderness Start with light palpation away from tendernessAssess rigidity and guarding (voluntary/involuntary)Assess for rebound tendernessPalpate all 9 regions
39 Deep Palpation Start in non-tender area-move towards tenderness Generally start in LLQPalpate for masses and deep tendernessPalpate for organsLiver, spleen, kidneysPalpate for AAA
40 Anterior Abdominal Exam: Percussion Nontender AbdomenLocation of Liver, SpleenSuccussion Splash of StomachGas in Small / Large IntestineFluid in the PeritoneumTender AbdomenLocation and Severity of TendernessPresence of signs of peritonitisGuarding, rigidity, rebound tenderness
41 Liver Palpation Start in RLQ/MCL Move hand up as patient inspires Gradually move position up towards costal margin with each inspriationFeel for liver edge as patient inspiresNormal liver edge smooth and softDescribe liver edge if abnormalHard/firm/nodularNormal liver cm in MCLPercuss top of liver in held inspirationScratch test
42 Liver palpation Hand held steady Patient inhales Patient breathes Hand lifted and moved up
43 Alternate Method Liver palpation Stand by the patient's chest."Hook" your fingers just below the costal margin and press firmly.
44 Hepatomegaly More than 1cm below the costal margin An exception is a congenitally large right lobe of the liverSevere, chronic emphysema pushes liver down
45 Pulsation transmitted from aorta or due to severe tricuspid valve insufficiency
46 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.
48 Splenic palpation Start in RLQ Move hand up with inspiration Reposition on expirationMigrate palpation towards left costal marginFeel for notched splenic surfaceIf spleen not felt roll patient in right decubitus positionSupport lrfy podterior costal margin with left hand and palpate under costal margin with right handPercuss Traube’s space for dullness
49 Splenic palpation Seldom palpable in normal adults. Causes include COPD, and deep inspiratory descent of the diaphragm.
50 Splenic palpationSupport lower left rib cage with left hand while patient is supine and lift anteriorly on the rib cage.
51 Splenic palpationPalpate upwards toward spleen with finger tips of right hand, starting below left costal margin.Have the patient take a deep breath.
52 Splenic palpation Deep technique used Starting point is RLQ, proceeding to LUQ
54 Kidney palpationPlace left hand posteriorly just below the right 12th rib. Lift upwards.Palpate deeply with right hand on anterior abdominal wall.
55 Kidney palpation Patient take a deep breath. Feel lower pole of kidney and try to capture it between your hands.
56 Right kidney may be felt to slip between hands during exhalation
57 Examination of AortaFlat palm placed over the the epigastrium to locate pulse
58 Examination of AortaPress down deeply in the midline above the umbilicus.The aortic pulsation is easily felt on most individuals.
59 Examination of AortaHands then oriented vertically on either side of midline with distal fingers at level of pulsation; equal pressure applied until pulsation is palpatedA well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.
60 Examination of AortaLateral width of pulsation is determined by space between index fingers or finger and thumb
61 Abdominal Aortic Aneurysm Palpable pulsatile massPatient feeling of pulsationOn rare occasions, a lump can be visible.May rupture leading to shock and deathIf ruptures into IVC = continuous murmur
63 Special exam Rebound Tenderness Murphy’s Sign McBurney’s Point Rovsing’s SignPsoas SignObturator SignCostovertebral tendernessSpinal percussion tendernessShifting DullnessFluid wave
64 Murphy’s Sign (acute cholecystitis) Examiner’s 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 inspirationHepatitis, subdiaphragmatic abscess Cholecystitis
65 McBurney’s PointLocalized 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.
66 McBurney’s Point (Common Causes) AppendicitisIncarcerated or strangulated herniaOvarian torsion (twisted Fallopian tube)Pelvic inflammatory diseaseAbdominal abscessHepatitisDiverticular diseaseMeckel''s diverticulum
67 Rovsing’s SignPatient will experience right lower quadrant pain (in region of McBurney’s Point) when left lower quadrant is palpated.
69 Iliopsoas SignPatient 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 examiner’s hand on thigh. If patient has an inflamed retrocecal appendix, this will produce pain.
70 Iliopsoas SignAnatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver.
71 Obturator SignInternally rotate right leg at the hip with the knee at 90 degrees of flexion. Will produce pain if inflamed appendix is in pelvis.
72 Obturator SignAnatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this maneuver.
73 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.
74 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.