Abdominal examination
Encyclopedia
The abdominal exam, in medicine
, is performed as part of a physical examination
, or when a patient presents with abdominal pain
or a history that suggests an abdominal pathology
.
The exam includes several parts:
and the bed or examination table should be flat. The patient's hands should remain at his/her sides with his/her head resting on a pillow. If the neck is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend his/her knees so that the soles of their feet rest on the table will also relax the abdomen.
Lighting - adjusted so that it is ideal.
Draping - patient should be exposed from the pubic symphysis
below to the costal margin
above - in women to just below the breast
s. Some surgeons would describe an abdominal examination being from nipples to knees.
Physicians have had concern that giving patients pain medications during acute abdominal pain may hinder diagnosis and treatment. Separate systematic review
s by the Cochrane Collaboration
and the Rational Clinical Examination refute this claim.
of liver disease. Though not all of these are observed in the abdomen, they can indicate liver disease, and are sometimes grouped with local hepatic findings. These stigmata include:
and you check for rebound tenderness and then want to auscultate you may no longer have a cooperative patient.
Pre-warm the diaphragm of the stethoscope
by rubbing it on the front of your shirt before beginning auscultation. One should auscultate in all four quadrants, but there is no true compartmentalization so sounds produced in one area can generally be heard throughout the abdomen. To conclude that bowel sounds are absent one has to listen for 5 minutes. Growling sounds may be heard with obstruction. Absence of sounds may be caused by peritonitis.
Another new technique to measure the borders of the liver is the "Kamil Ševela" technique, which I was taught in the hospital. You place the stethoscope on the xiphoid process for auscultation. You scratch from below the right nipple/breast and you hear clearly the liver borders. The first sound is when the liver appears, and when the sound disappears it is the end of the liver. The sounds are clearly audible, and it's a very useful tool to know the borders of the liver.
Assessing muscle tone- This is done by pressing a hand against the abdominal wall. There are 3 reactions that indicate pathology:
Examination of the spleen
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
, is performed as part of a physical examination
Physical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
, or when a patient presents with abdominal pain
Abdominal pain
Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem...
or a history that suggests an abdominal pathology
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
.
The exam includes several parts:
- Setting and preparation
- InspectionInspection (medicine)In medicine, inspection is the thorough and unhurried visualization of the client. This requires the use of the naked eye.During inspection, the examiner observes:External signs:...
(for example, "nondistended" or "ND") - AuscultationAuscultationAuscultation is the term for listening to the internal sounds of the body, usually using a stethoscope...
(for example, "BSBorborygmusBorborygmus also known as stomach growling, rumbling, gurgling, grumbling or wambling, is the rumbling sound produced by the contraction of muscles in the stomach and intestines of animals, including humans...
normoactive" or "BS+" - PalpationPalpationPalpation is used as part of a physical examination in which an object is felt to determine its size, shape, firmness, or location...
(for example, "no hepatosplenomegalyHepatosplenomegalyHepatosplenomegaly is the simultaneous enlargement of both the liver and the spleen . Hepatosplenomegaly can occur as the result of acute viral hepatitis or infectious mononucleosis, or it can be the sign of a serious and life threatening lysosomal storage disease...
" or "HSM", "soft", "nontender" or "NT") - PercussionPercussion (medicine)Percussion is a method of tapping on a surface to determine the underlying structure, and is used in clinical examinations to assess the condition of the thorax or abdomen. It is one of the four methods of clinical examination, together with inspection, palpation and auscultation...
Setting and preparation
Position - patient should be supineSupine position
The supine position is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the...
and the bed or examination table should be flat. The patient's hands should remain at his/her sides with his/her head resting on a pillow. If the neck is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend his/her knees so that the soles of their feet rest on the table will also relax the abdomen.
Lighting - adjusted so that it is ideal.
Draping - patient should be exposed from the pubic symphysis
Pubic symphysis
The pubic symphysis or symphysis pubis is the midline cartilaginous joint uniting the superior rami of the left and right pubic bones. It is located anterior to the urinary bladder and superior to the external genitalia; for females it is above the vulva and for males it is above the penis...
below to the costal margin
Costal margin
The costal margin, sometimes referred to as the costal arch, is the medial margin formed by the false ribs and one true rib -- specifically, from the seventh rib to the tenth rib....
above - in women to just below the breast
Breast
The breast is the upper ventral region of the torso of a primate, in left and right sides, which in a female contains the mammary gland that secretes milk used to feed infants.Both men and women develop breasts from the same embryological tissues...
s. Some surgeons would describe an abdominal examination being from nipples to knees.
Physicians have had concern that giving patients pain medications during acute abdominal pain may hinder diagnosis and treatment. Separate systematic review
Systematic review
A systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine...
s by the Cochrane Collaboration
Cochrane Collaboration
The Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
and the Rational Clinical Examination refute this claim.
Inspection
The patient should be examined for: -- masses
- scars, sinuses
- lesions
- signs of trauma
- bulging flanksBulging flanksIn medicine, bulging flanks refers to a sign for ascites. If, on inspection , the sides of the abdomen bulge outward in an unusual fashion on a patient, they likely have fluid in the abdomen...
- best done from the foot of the bed - jaundiceJaundiceJaundice is a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae , and other mucous membranes caused by hyperbilirubinemia . This hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluid...
/scleral icterus - abdominal distension
- caput medusae - dilated blood vessels radiating from the umbilicus (may be present in liver failure)
- cough impulse
Stigmata of liver disease
There are several stigmataStigmata
Stigmata are bodily marks, sores, or sensations of pain in locations corresponding to the crucifixion wounds of Jesus, such as the hands and feet...
of liver disease. Though not all of these are observed in the abdomen, they can indicate liver disease, and are sometimes grouped with local hepatic findings. These stigmata include:
- General: spider angiomata, temporalTemple (anatomy)Temple indicates the side of the head behind the eyes. The bone beneath is the temporal bone as well as part of the sphenoid bone.-Anatomy:Cladists classify land vertebrates based on the presence of an upper hole, a lower hole, both, or neither in the cover of dermal bone which formerly covered the...
wasting, fetor hepaticusFetor hepaticusFetor hepaticus or foetor hepaticus , also known as breath of the dead, is a condition seen in portal hypertension where portosystemic shunting allows mercaptans to pass directly into the lungs. It is a late sign in liver failure. Other possible causes are the presence of ammonia and ketones in the...
, asterixisAsterixisAsterixis is a tremor of the wrist when the wrist is extended , sometimes said to resemble a bird flapping its wings. This motor disorder is characterized by jerking movements and is associated with various encephalopathies due especially to faulty metabolism...
(flapping tremor) - Hands: clubbing, thenarThenar eminenceThe thenar eminence refers to the group of muscles on the palm of the human hand at the base of the thumb...
wasting, Dupuytren's contractureDupuytren's contractureDupuytren's contracture , is a fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully extended...
, palmar erythemaPalmar erythemaPalmar erythema is reddening of the palms at the thenar and hypothenar eminences.-Causes:It is associated with various physiological as well as pathological changes, the principal one of which is portal hypertension. It is also seen in patients with liver dysfunction, such as chronic liver disease... - Estrogen related: spider nevi
- Estrogen-related in males: testicular atrophy, gynecomastiaGynecomastiaGynecomastia or Gynaecomastia, , is the abnormal development of large mammary glands in males resulting in breast enlargement. The term comes from the Greek γυνή gyné meaning "woman" and μαστός mastós meaning "breast"...
- Estrogen-related in males: testicular atrophy, gynecomastia
- Associated with portal hypertension: hematocheziaHematocheziaHematochezia is the passage of fresh blood per anus, usually in or with stools . Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper GI bleed...
(blood in stoolFecesFeces, faeces, or fæces is a waste product from an animal's digestive tract expelled through the anus or cloaca during defecation.-Etymology:...
), hematemesisHematemesisHematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract. Patients can easily confuse it with hemoptysis , although the latter is more common.-Signs:...
- gastric bleed, esophageal varicesEsophageal varicesIn medicine , esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus...
, caput medusaeCaput medusaeCaput medusae is the appearance of distended and engorged paraumbilical veins, which are seen radiating from the umbilicus across the abdomen to join systemic veins...
(rare) - venous distension, ascitesAscitesAscites is a gastroenterological term for an accumulation of fluid in the peritoneal cavity.The medical condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy. Although most commonly due to cirrhosis and severe liver...
Auscultation
Auscultation is sometimes done before percussion and palpation, unlike in other examinations. It may be performed first because vigorously touching the abdomen may disturb the intestines, perhaps artificially altering their activity and thus the bowel sounds. Additionally, it is the least likely to be painful/invasive; if the person has peritonitisPeritonitis
Peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...
and you check for rebound tenderness and then want to auscultate you may no longer have a cooperative patient.
Pre-warm the diaphragm of the stethoscope
Stethoscope
The stethoscope is an acoustic medical device for auscultation, or listening to the internal sounds of an animal body. It is often used to listen to lung and heart sounds. It is also used to listen to intestines and blood flow in arteries and veins...
by rubbing it on the front of your shirt before beginning auscultation. One should auscultate in all four quadrants, but there is no true compartmentalization so sounds produced in one area can generally be heard throughout the abdomen. To conclude that bowel sounds are absent one has to listen for 5 minutes. Growling sounds may be heard with obstruction. Absence of sounds may be caused by peritonitis.
Another new technique to measure the borders of the liver is the "Kamil Ševela" technique, which I was taught in the hospital. You place the stethoscope on the xiphoid process for auscultation. You scratch from below the right nipple/breast and you hear clearly the liver borders. The first sound is when the liver appears, and when the sound disappears it is the end of the liver. The sounds are clearly audible, and it's a very useful tool to know the borders of the liver.
Palpation
- All 9 areas - light then deep.
- In light palpation, note any palpable mass.
- In deep palpation, detail examination of the mass, found in light palpation, and Liver & Spleen
- Palpate the painful point at the end.
Assessing muscle tone- This is done by pressing a hand against the abdominal wall. There are 3 reactions that indicate pathology:
- guarding (muscles contract as pressure is applied)
- rigidity (rigid abdominal wall- indicates peritoneal inflammation)
- rebound (release of pressure causes pain)
- hernial orifices if positive cough impulses
Percussion
- it is common practice to start percussing in a quadrant where there is no pain/discomfort and to percuss the painful quadrant(s) last. making sure to percuss all the 9 areas.
- percuss the liver from the right iliac region to right hypochondrium
- percuss for the spleen from the right iliac region to the left hypochondrium and the left iliac to the left hypochondrium.
Examination of the spleen
- Castell's signCastell's signCastell's sign is a medical sign assessed to evaluate splenomegaly and typically part of an abdominal examination. It is an alternative physical examination maneuver to percussion over Traube's space....
or alternatively Traube's spaceTraube's spaceTraube's space is an anatomic region of some clinical importance. It's a crescent-shaped space, encompassed by the lower edge of the left lung, the anterior border of the spleen, the left costal margin and the inferior margin of the left lobe of the liver...
Other
- Digital rectal exam - Abdominal examination is not complete without a digital rectal exam.
- Pelvic examination only if clinically indicated.
Suspected appendicitis or peritonitis
- Rebound tendernessRebound tendernessRebound tenderness is a clinical sign that a doctor or other health care provider may detect in physical examination of a patient's abdomen. It refers to pain upon removal of pressure rather than application of pressure to the abdomen...
- pain elicited by the release of palpation by the examiner - Psoas signPsoas signThe psoas sign is a medical sign that indicates irritation to the iliopsoas group of hip flexors in the abdomen, and consequently indicates that the inflamed appendix is retrocaecal in orientation...
- pain when tensing the psoas muscle - Obturator signObturator signThe obturator sign, also known as the Cope sign, is an indicator of irritation to the obturator internus muscle. The technique is carried out on each leg in succession. First the patient lies on his back with the right hip flexed at 90 degrees. The examiner then holds the patient's right ankle in...
- pain when tensing the obturator muscle - Rovsing's signRovsing's signthumb|right|Rovsing's sign is pain in the [[RLQ]] experienced when the [[left lower quadrant|LLQ]] is palpated.Rovsing's sign, named after the Danish surgeon Niels Thorkild Rovsing, is a sign of appendicitis...
- pain in the right iliac fossa on palpation of the left side of the abdomen - Carnett's signCarnett's signIn medicine, Carnett's sign is an eponymous finding on clinical examination in which abdominal pain remains unchanged or increases when the muscles of the abdominal wall are tensed. For this part of the abdominal examination, the patient can be asked to lift the head and shoulders from the...
- pain when tensing the abdominal wall muscles - Patafio's sign - pain when the patient is asked to cough whilst tensing the psoas muscle
- Cough test - pain when the patient is asked to cough
External links
- Abdominal exam - a practical guide to clinical medicine from the University of California, San DiegoUniversity of California, San DiegoThe University of California, San Diego, commonly known as UCSD or UC San Diego, is a public research university located in the La Jolla neighborhood of San Diego, California, United States...
. - Abdominal examination video
- Pediatric Abdominal examination video