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Physical Exam Abdomen

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General

  • The abdomen should be examined with the patient supine[1]
  • Rectal examination should be considered depending on presentation
  • Genitourinary examination should be considered depending on presentation

Inspection

  • General
    • How does the patient look?
    • Do they look sick?
  • Skin
    • Color: erythema, ecchymosis, white, black
    • Trophic changes (altered hair growth, sweat production)
    • Scars
    • Cyanosis
  • Swelling
  • Muscle tone: atrophy, hypertrophy
  • Deformity: asymmetry, rotation, amputation
  • Areas of interest
    • Presence of surgical scars
    • Obesity of abdomen
    • Distension
    • Masses or bulges
    • Grey Turner sign: ecchymosis of the flank and groin
    • Cullen's sign: periumbilical ecchymosis
    • Pink or purple striae
    • Caput Medusa: distended veins flowing away from the umbilicus
    • Ascites
    • Swollen lymph nodes
  • Also look for
    • Pallor (conjunctival, mucosal)
    • Jaundice or scleral icterus
    • Petechiae

Auscultation

  • Normal: low pitched, gurgling
    • Normally heard every 5-10 seconds
  • Hyperactive
  • Hypoactive
  • Absent
  • Bruit[2]

Palpation

  • General
    • Patient should be relaxed
    • Start with light palpation before deep palpation
    • Pressure should be slow, steady
    • Save self reported area of pain for last
    • May require “distraction” by examiner
  • Palpate by region/ area
    • Right upper quadrant
    • Right flank
    • Right lower quadrant
    • Epigastric
    • Periumbilical
    • Suprapubic
    • Left upper quadrant
    • Left flank
    • Left lower quadrant
  • Potential Findings
    • Focal tenderness
    • Nonfocal or diffuse tenderness
    • Organomegaly (spleen, liver)
    • Masses
    • Rebound tenderness
    • Guarding (voluntary or involuntary)
    • Crepitus
    • Pulsatile mass
    • Hernia
  • Additional pearls
    • Asking the patient to cough can increase intra-abdominal pressure and increase protrusion of mass

Percussion

  • General
    • Can be performed "separately" or as part of palpation exam
    • Tympany: heard over air-filled viscera
    • Dull: heard over solid organs
  • Define borders of liver, spleen
    • Note will change from tympanitic to dull
  • Costovertebral angle
  • Check for ascites

Rectal

  • Externally inspect for
    • External blood
    • Fissure
    • Fistula
    • External hemorrhoids
  • Palpation (digital rectal exam)
    • Use a lubricated gloved finger
    • Slide slowly to, gently to dilate the sphincter
    • Palpate for hemorrhoids, foreign body
    • Presence or absence of stool in rectal vault
  • Prostate can be examined if clinically appropriate
    • After exam
    • Examine finger for any signs of blood or melena in stool
    • Consider guaiac test as clinically appropriate

Special Tests

  • Appendicitis
    • McBurney's point: tenderness ⅓ of the distance from ASIS to umbilicus
    • Rovsing’s sign: deep palpation of the left lower quadrant causing pain on the right lower quadrant
    • Psoas sign; activation of right psoas muscle with hip flexion recreating pain
    • Obturator sign: Flexing, internally rotating hip and knee causing increased pain

See Also


  1. Bates B. 1991. A Guide to Physical Examination and History Taking. 5th Ed. Pennsylvania: J.B. Lippincott Company. p 339–368.
  2. Seidel HM, Ball JW, Dains JE, Flynn JA, Solomon BS. 2010. Mosby's Physical Examination Handbook. Vol. 13. 7th Ed. Mosby: Elsevier. p 92–150.
Created by:
John Kiel on 19 August 2021 14:02:26
Authors:
Last edited:
9 April 2022 17:14:58
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