1. The Abdomen: History & Physical Exam
Dr. Gwen Hollaar, Dr. Lanice Jones Dr. Robert Lee
Lao 2006

2. Objectives
Review important information students need to obtain on history for the GI and GU systems
How to teach abdominal exam
How to teach genital and gynecological exam

3. History Taking – Abdominal Complaints
When patients present with abdominal symptoms, pain is a common symptom
Remember to ask the following questions about the pain (WWQQAAAB)
Where is the pain?
When do you get the pain? (Example: before or after eating, before or after a bowel movement?)
Quality: sharp, dull, stabbing, cramping / severity
Quantity: constant or intermittent (how frequent)
Aggravate: does anything make the pain worse?
Alleviate: does anything make the pain better?
Belief – what does the patient think is causing the pain

4. Abdominal Pain Acute cholecystitis Perforated esophagus
Peptic ulcer
Acute cholecystitis
Perforated esophagus
Myocardial infarction
Acute cholecystitis
Duodenal ulcer
Hepatitis
Congestive hepatomegaly
Pyelonephritis
Appendicitis
Rt pneumonia / Pulmonary embolus
Splenic rupture / Splenomegaly
Gastric ulcer
Perforated colon
Pyelonephritis
Lt pneumonia / Pulmonary embolus
GI Obstruction
Acute pancreatitis
Early appendicitis
Appendicitis
Salpingitis / Tubo-ovarian abscess
Ruptured ectopic pregnancy
Renal / Ureteric / Bladder stone
UTI
Mesenteric adenitis
Meckel’s diverticulitis
Psoas abscess
Perforated colon
Inguinal hernia
Salpingitis / Tubo-ovarian abscess
Ruptured ectopic pregnancy
Renal / Ureteric / Bladder stone
UTI
Perforated colon
Inguinal hernia

5. Associated Symptoms of the GI system
Difficulty swallowing (dysphagia)
Fluids and/or solids
Where does it feel like food is getting stuck
Associated pain with swallowing or not
Vomiting
Bilious / nonbilious / fecal / hematemesis
Projectile / nonprojectile
Heartburn or Indigestion
These can be vague symptoms…. Be sure to get a complete description of this discomfort to better determine its etiology (cause)

6. Associated Symptoms of the GI system
Jaundice
Associated with pain or not
History of drinking large amounts of alcohol
History of travel and diet
Change in Bowel Habits
Frequency
What is their normal bowel habit pattern
Has this recently changed
Stool appearance
Colour: pale, dark brown, black (melena)
Formed, poorly formed, watery
Mucous
Passing visible worms or fragments

7. Associated Symptoms of the GI system
Bleeding per rectum (hematochezia)
Color of blood (bright red or dark red)
Only with bowel movements or any time
Associated with perianal pain or perianal swelling
Loss of weight or loss of appetite
Approximate weight loss and over how much time
Abdominal distention
Fluctuates or constant

8. Associated Symptoms of the GU system
Dysuria: pain on passing urine
Frequency
Polyuria or oliguria or anuria
Nocturia: need to pass urine at night
Urgency
Change in force of urinatation
Difficulty in beginning or maintaining urinary stream
Complete or incomplete bladder emptying
Incontinence of urine
Hematuria: painful or painless
Abdominal or flank pain

9. Associated Symptoms of the GU system
Gynecological history:
Menstrual history
Last menstrual period
Duration of menstrual flow
Amount of menstrual flow
Pain with menstruation
Intermenstrual or postcoital bleeding
Abnormal vaginal discharge (get description)

10. Abdominal Examination
Inspection
Auscultation
Percussion
Palpation
(Some textbooks suggest changing to this order because palpation is often the most painful in patients with abdominal pain).

11. Inspection Remember extra-abdominal inspection Jaundice Sclera
Under the tongue
Palm of hands

12. Inspection for Other signs of Liver Disease
Skin
Jaundice
Spider nevi
Caput medusa
Peripheral edema
Hands
Palmer erythema
Dupytren’s contracture
Breasts & Genitalia
Gynecomastia
Testicular atrophy
Neurologic
Flapping tremor

13. Manifestations of Chronic Liver Disease
Ascites
Gynecomastia
Edema
Spider Nevi

14. Inspection Abdominal inspection Presence of surgical scars
Exaggerated collateral veins on abdominal wall
Shape and symmetry of abdomen
Scaphoid or distended
Bulging flanks (may suggest ascites)
Masses or local areas of swelling
Remember this includes the groin
(ie. lymphadenopathy or hernias)

15. Inspection of Abdomen Caput Medusa
(sign of portal hypertension / cirrhosis)
Umbilical Hernia

16. Auscultation Bowel Sounds Abdominal Bruits Present Absent
Tinkling bowel sounds suggest mechanical obstruction
Absent
Suggests ileus
Abdominal Bruits
Check at renal arteries and at bifurcation of aorta

17. Abdominal Exam – Think Anatomically

18. Abdominal Exam – Think Anatomically

19. Percussion
Percuss over all 4 quadrants to determine if there is tenderness
Localized areas of tenderness on percussion suggests peritonitis or peritoneal irritation

20. Abdominal Pain
You can remind your students that the abdominal cavity has two peritoneum
Visceral peritoneum: lines solid organs and bowel
Parietal peritoneum: lines the abdominal cavity on the inside of the abdominal wall
Stimulus to visceral peritoneum causes diffuse abdominal pain
Causes include:
Visceral (i.e. bowel) distention or swelling
Strong contraction of bowel
Stimulus to parietal peritoneum causes localized abdominal pain
Causes include irritation to parietal peritoneum
Inflamed or purulent internal organs (i.e. appendicitis)
Perforation of hollow viscous
Hemoperitoneum

21. Percussion
After percussing all 4 quadrants, particular areas you want to percuss include:
Liver
Spleen
Percuss for ascites or distended bladder (suprapubic region) if suspected
General principles of percussion
Sound will be dull over solid organs and tympanic (hollow) over air-filled organs
Percuss from resonant area to dull area

22. Percussion Liver percussion Assess of liver size
Percuss along mid-clavicular line from chest towords subcostal area to determine upper border of liver
Percuss along mid-clavicular line from right lower quadrant superiorly to determine lower border of liver
Measure the area that is dull as this is the measurement of the liver span

23. Percussion Spleen percussion Assess for enlarged spleen
Percuss over Traube’s space
If dull sound, the spleen is enlarged
If tympanic (hollow) sound, the spleen is not enlarged
You can also percuss from RLQ to LUQ to assess when there is a transition from a hollow sound to a dull sound
Traube’s space

24. Percussion for Ascites

25. Percussion for Ascites
Patient is lying supine
Percuss from near the umbilicus laterally
Note where the sound changes from tympanic (hollow) to dull
Dullness is where the intra-abdominal fluid level is located while the patient lies supine

26. Percussion for Ascites
Now roll patient to the side
Percuss from around the umbilicus laterally
Note where the sound changes from tympanic (hollow) to dull
Dullness is where the intra-abdominal fluid level now is located while the patient lies on his side
If the line has shifted with patient position, the patient probably has ascites

27. Palpation First palpate all quadrants to assess for:
Tenderness
Masses
It is best to start palpation in quadrant where there is least tenderness and end in quadrant where there is most tenderness
You should also palpate for liver and spleen

28. Palpation of Liver
Begin in mid-clavicular line (or just lateral to rectus abdominis muscle) at least 10 cm below costal margin (i.e. below where the liver edge should be)
Use your left hand to push anteriorly against back
Use your right hand to gently press in and upwards and have patient take a deep breath
Move your hand more superiorly, press again and have patient take another deep breath
The liver edge will slide under your fingers when the patient takes a deep breath
The liver edge in not usually palpable in a patient with a normal liver

29. Palpation of Spleen
Begin in right lower quadrant so that an enlarged splenic edge will brush against your fingers
Use your left hand to push anteriorly against back
Use your right hand to gently press in and upwards and have patient take a deep breath
Move your hand more superiorly, press again and have patient take another deep breath
The splenic edge will slide under your fingers when the patient takes a deep breath
The splenic edge will not be palpable in a patient with a normal spleen
Palpate upwards in this direction, from RLQ to LUQ

30. Palpation for Ascites – Fluid Wave
You need an assistant or have the patient help you
Have your assistant (or the patient) place their hand on the midline of the abdomen
This prevents you from feeling any transmitted wave through the subcutaneous fat
Use one hand to tap the lateral abdomen while the other hand is pressed gently against the opposite lateral abdomen to feel for the transmitted fluid wave.
Fluid will transmit the tap, air does not
This examination can be difficult to know for sure if there is ascites or not.

31. Kidney examination
Examine for tenderness over kidneys by gently tapping the flanks with your fist while having the patient lean forward

32. Kidney Examination
Physicians do attempt to feel the kidneys by doing a bimanual abdominal exam
Unless the kidney is really enlarged or the patient very thin, it is difficult to actually palpate a kidney

33. Examination of the Groins
Remember: An abdominal exam in NOT complete without examination of the groins

34. Examination of the Groins
Inspection and Palpation with patient supine
Look and feel for masses or swelling (lymphadenopathy or hernias)
Inspection and Palpation with patient standing
Again look and feel for masses or swelling
Have patient perform Valsalva maneuver or cough
Place your index finger over/into external inguinal ring and have patient cough to feel for inguinal hernia

35. Examination of the Anus / Rectum
This is an important part of the examination in patient presenting with abdominal complaints
On examination:
Inspect for external hemorroids or tags
Palpate for masses
Palpate size/consistency of prostate in men
Palpate cervix in women
Feel sphincter tone
Look for blood on your gloved finger

36. Examination of the Anus / Rectum

37. Examination of Male Genitalia
This examination is done selectively depending upon the patient’s symptoms
On examination of the scrotum, you are looking for:
Scrotal tenderness (i.e. epididymitis)
Scrotal swelling (i.e. hydrocele)
Scrotal masses (i.e. testicular tumour)

38. Gynecological Examination
Cover trunk of patient
Have hips and knees flexed and thighs abducted
Need good light
Examine the vulva (inspection and palpation)
Bimanual examination with 2 fingers into vagina and other hand palpating the suprapubic area
Palpate cervix and right and left adnexae
Speculum examination

40. How do you teach examination of personal areas?
How do you teach breast, male genitalia, and gynecological examinations?
Can be difficult thing to teach as teachers, students and patients can be uncomfortable
But these areas DO need to be taught because they are essential clinical skills for students to know
Can teach with patients or with models
When teaching with patients:
Instruct the student ahead of time what the examination consists of or have them read about it (best to do both)
Make sure patient is aware and comfortable with what you will be doing
Demonstrate it on the patient first and then have your student do the examination while you are there so you can correct them as needed

41. Questions or Comments