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1 IPC II ΠQuick Review ΠAbdominal Examination

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1 IPC II Œ Quick Review Œ Abdominal Examination IPC II – Quick Review – Abdominal Examination Abdominal Examination Goals and Objectives: 1. Review normal abdominal examination a. Inspection, auscultation, percussion and palpations techniques I. Inspection Surface characteristics: Skin, Venous return, Lesions/scars, Tautness/ Striae, Contour, Location of umbilicus, Symmetry, Surface motion - Motion with respiration, Peristaltic waves, Pulsations Causes of distention: (The 9 F’s) Fat, Fluid, Feces, Fetus, Flatus, Fibroid, Full bladder, False pregnancy, Fatal tumor Types of distention: –Generalized –Below umbilicus –Above umbilicus –Asymmetric II. Palpation a. Used to assess the organs, detect muscle spasm, fluid, and tenderness b. Begin with Light Palpation of all 4 quadrants to detect muscular resistance (indicating peritoneal irritation) and areas of tenderness. Palpate the area that the patient complains of pain in-last. c. Progress to Moderate Palpation over all 4 quadrants to elicit tenderness that was not present with Light Palpation d. Use Deep Palpation to thoroughly delineate abdominal organs and to detect less obvious masses e. If a mass can no longer be detected when the patient lifts his/her head from the table (i.e., contracting the abdominal muscles), it is in the abdominal cavity, and not the abdominal wall f. Palpate the umbilical ring, and around the umbilicus for potential hernias III. Percussion a. Used to detect the size and density of the abdominal organs, fluid (ascites), air (gastric distention), or fluid-filled/solid masses b. Percuss all 4 quadrants for a sense of tympany or dullness 1. Tympany is heard over regions of air, i.e., stomach and intestines 2. Dullness is heard over organs and solid masses c. Liver Span 1. Begin at the right midclavicular line, over an area of tympany, and then percuss until you hear dullness 2. Percuss up to determine the lower border 3. To determine the upper border, begin at the midclavicular line at a region of lung resonance, and percuss downward until you hear dullness 4. The usual span is approximately 6-12 cm 5. You can also assess the following for the liver: a. Liver descent ~ have the patient hold a deep breath, and percuss what should be a descent of 2-3 cms d. Spleen 1. Percuss just posterior to the midaxillary line on the left side, in several directions. 1 IV. Auscultation a. This always precedes percussion and palpation in the abdominal exam because these techniques may alter the frequency and intensity of bowel sounds b. Is used to assess bowel motility and to discover vascular sounds 1. Bowel Sounds a. Use the diaphragm b. Listen for bowel sounds and note frequency and character c. They ranger from 5-35 per minute d. The absence of bowel sounds is established only after 5 minutes of continuous listening e. Must auscultate all 4 quadrants 2. Vascular Sounds a. Use the bell b. Listen for bruits in the aortic, renal, iliac, and femoral arteries c. Friction rubs, due to inflammation of the peritoneal surface of abdominal organs, can be heard with the diaphragm, in association with respiration 2. Landmarks of the Abdomen ~ the abdomen is either divided into 4 or 9 quadrants: a. 4 Quadrants: 1. An imaginary line exists &omthe sternum to the pubis, through the umbilicus 2. A second line runs perpendicular, horizontally through the umbilicus 3. This results in 4 quadrants: RUQ, LUQ, RLQ, and LLQ b. 9 Quadrants: 1. 2 horizontal lines, one across that dissects the costal margin, and another that runs along the iliac crests 2. 2 vertical lines that dissect the mid-clavicular line/point 3. This results in 9 quadrants (from superior to inferior): Right Hypochondriac, Epigastric, Left Hypochondriac; Right Lumbar, Umbilical, Left Lumbar; Right Inguinal, Hypogastric, Left Inguinal. 3. You should learn the skills of examining an abnormal abdomen a. Be comfortable assessing the abdomen for distention and tympany 1. Distention (evaluated during inspection) a. The contour of the abdomen is the abdominal profile from the rib margin to the pubis, viewed in the horizontal plane 1. Expected contours of the abdomen include: a. Flat- well muscled, athletic adults b. Rounded (convex) - young children, or fat adults c. Scaphoid (concave)- thin adults 2. Abnormal contours of the abdomen include: a. Generalized, symmetric distention - obesity, enlarged organs, and fluid or gas 2 b. Distention form the umbilicus to the symphysis - ovarian tumor, pregnancy, uterine fibroids, or a distended bladder c. Distention of the upper half, above the umbilicus - carcinoma, pancreatic cyst, or gastric dilation d. Asymmetric distention or protrusion - hernia, tumor, cysts, bowel obstruction, or enlargement of abdominal organs b. Having the patient hold his/her breath may unmask some previously hidden masses due to compression of the diaphragm on the abdominal organs, while having them lift their head may reveal superficial abdominal wall masses due to contraction of the rectus abdominis 2. Tympany (evaluated during percussion) a. The musical note, high pitched sound expected during percussion of regions with air, i.e., the intestines or stomach 4. Know methods of evaluating Ascites a. Shifting dullness 1. Have the patient lie on one side, and percuss for tympany and dullness, and mark the borders 2. If the patient does not have ascites, the borders will remain constant 3. If the patient has ascites, the border of dullness shifts to the dependent side as the fluid resettles with gravity b. Fluid wave 1.This procedure requires 3 hands, so get an assistant to help 2.With the patient supine, have the assistant press the edge of the hand firmly along the vertical midline of the abdomen 3. Place your hands on both sides of the abdomen, and strike one side with your fingertips 4.Feel for a fluid wave in the other hand, suggesting ascites potentially c. Puddle's sign 1.This allows you to test for fluid pooling 2.Ask the patient to assume the knee-chest position and maintain that position for several minutes to allow fluid to pool by gravity 3. Percuss the umbilical area for dullness to determine the presence of fluid d. Auscultatory percussion 1. Have the patient void, and then stand for 3 minutes to allow fluid to gravitate to the pelvis 2. Place diaphragm of stethoscope above the symphysis pubis in the midline 3. With the other hand, flick percussion to three or more sites from the costal margin down toward the pelvis 4. In patients with ascites, the percussion note changes above the pelvic border at the fluid level (as opposed to changing from a sharp to dull note at the pelvic border) 3 5. Know maneuvers of palpation of given organs: a. Liver 1. Place your left hand under the patient at the 11th and 12th ribs, pressing upward to elevate the liver towards the abdominal wall 2. Palpate the liver with the right hand 3. Ordinarily the liver is not palpable, except in cases of very skinny individuals b. Gallbladder 1. Palpate the liver margin at the lateral border of the rectus abdominis muscle for the gallbladder. A healthy gallbladder is not palpable c. Spleen 1. Slide your left hand under the patients left costovertebral angle, pressing upward with the hand to lift the spleen anteriorly towards the abdominal wall 2. Palpate below the left costal margin with your right hand 3. A healthy spleen is not palpable d. Kidneys 1. Have the patient assume a sitting position, while you place the palm of your hand over the costovertebral angle of the right side, and then strike your hand a. Repeat this for the opposite side b. This allows you to determine kidney tenderness 2. To assess the left kidney, have the patient lie supine while putting your left hand over the patient's flank to elevate the kidney towards the kidney, then palpate over the left costal margin with the other hand a. The left kidney should not be palpable b. Perform the same exam for the right kidney, but because of its anatomical location, it is much more likely to be palpable e. Aorta 1. While the patient is supine, palpate to the left of the midline, feeling for the aortic pulsation a. A lateral pulsation suggests an aortic aneurysm, and should be in an anterior position in normal adults b. An alternative technique would be to place the thumb on one side of the aorta, and the fingers on the other, pressing the fingers deeply inward to feel the pulsation. f. Urinary Bladder 1. The bladder is not palpable in a healthy individual unless it is distended with urine 2. You can determine the distended bladder outline with percussion (low percussion note will be elicited) 6. Know signs and symptoms of peritoneal irritation: a. Rebound tenderness (Blumberg's sign) 1. This maneuver is used to determine peritoneal irritation 2. Hold your hand at a 90 degree angle to the abdomen, press gently and deeply into a region remote from the area of discomfort 3. Rapidly withdraw your hand and fingers 4. As the organs return/rebound to their original location, there will be a sharp pain at the site of peritoneal inflammation b. Iliopsoas test 1. Perform this test when you suspect appendicitis 2. While the patient is supine, place your hand over the lower thigh, then ask the patient to raise the thigh (hip flexion) while you resist 3. Positive iliopsoas sign will experience lower quadrant pain 4 c. Obturator test 1. Perform this test when you suspect a ruptured appendix or a pelvic abscess 2. Pain in the hypogastric region is a positive sign 3. While the patient is supine, have them flex the right leg at the hip and knee to 90 degrees 4. Hold the leg above the knee, grasp the ankle, and rotate the leg laterally and medially d.
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