abdominal examination.2

7/27/2019 Abdominal Examination.2

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PEMERIKSAAN ABDOMEN

Dr. SUHAEMI, SpPD, Finasim


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General principles of exam

Abdominal Examination


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The History and Physical in

Perspective

70% of diagnoses can be made based onhistory alone.

90% of diagnoses can be made based on

history and physical exam.Expensive tests often confirm what isfound during the history and physical.


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Equipment for physical examination

RequiredStethoscope

Tongue blades

Penlight

Tape measure

Sphygmomanometer

Reflex hammerSafety pins

Optional

Gloves

Gauze pads

Lubricant gel

Nasal speculum

Turning fork: 128 Hz,512Hz

Pocket visual acuitycard

Oto-ophthalmoscope


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Important aspects of physical

examination----physicianElegant appearance

Decent manner

Kind attitude

Highly responsibility

Good medical

morals


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examination---physicianWash your hands,preferably while thepatient is watching

Washing with soapand water is aneffective way to

reduce thetransmission ofdisease


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How to perform the physical

examination?

Exposing only the

area that are being

examined

Offer a chaperone forboth sexes.

Explain what you're

going to do

Sequential


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examinationThe examiner shouldcontinue speaking tothe patient

Showing care to hisdisease and answer topatients questions

It can not only releasepatients nerviness, butalso help to establishthe good physician-patient relationship


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Gloves should be worn when..

Examining any

individual with

exudative lesions or

weeping dermatitisWhen handling

blood-soiled orbody

fluid-soiled sheets

or clothing


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Good light

Relaxedpatient

Full exposure

of abdomen


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Have the patient

empty their bladder

before examination

Have the patient lie ina comfortable, flat,

supine position

Have them keep their

arms at their sides or

folded on the chest


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Before the exam, ask

the patient to identify

painful areas so that

you can examinethose areas last

During the exam pay

attention to theirfacial

expression to assessfor sign of discomfort


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Use warm hand,

warm stethoscope,

and have short finger

nailsApproach the patient

slowly and

deliberately

explaining what youwill be doing


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Stand right side of thebed

Exam with right handHead just a littleelevated

Ask the patient to

keep the mouthpartially open andbreathe gently


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If muscles remain

tense, patient may

be asked to restfeet on table with

hips and knees

flexed


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Other helpful points on examination

Take a spare bed

sheet and drape it

over their lower bodysuch that it just

covers the upper

edge of their

underwear


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If the patient is ticklishor frightened

Initially use the

patients hand underyours as you palpate

When patient calmsthen use your hands

to palpate.Watch the patientsface for discomfort.


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Think

Anatomically


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Think Anatomically

When looking,

listening, feeling and

percussing imagine

what organs live inthe area that you are

examining.


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Right Upper Quadrant (RUQ)

liver, gallbladder,

duodenum,

right kidneyand hepatic

flexure of colon


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Right Lower Quadrant (RLQ)

Cecum,

appendix (in

case of female,right ovary &

tube)


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Left Lower Quadrant (LLQ)

Sigmoid

colon (in case

of female, leftovary & tube)


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Left Upper Quadrant (LUQ)

Stomach,

spleen, left

kidney, pancreas(tail), splenic

flexure of colon


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Epigastric Area

Stomach,

pancreas

(head andbody), aorta


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Landmarks of the abdominal wall,

Costal margin,

umbilicus, iliac crest,

anterior superior iliac

spine, symphysispubis, pubic tubercle,

inguinal ligament,

rectus abdominis

muscle, xiphoidprocess.


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Physical Examination of the

Abdomen

Inspection

Auscultation

PercussionPalpation

Special Tests


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Inspection

Abdominal examination


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Appearance of the abdomen

Is Aortic pulsation?

Is it flat orScaphoid

(Normally)?Distended?

If enlarged, does this

appearsymmetric?With bulging or

moving?


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Symmetrical in shape

Scaphoid or flat in young

patients of normal weight

slightly full but not distended in older age

group due to poor muscle tone or in

subjects who are mildly overweight


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Appreciation of abdominal contours

Standing at the foot ofthe table and looking uptowards the patient'shead.

Lower yourself until the

anterior abdominalwall and ask the patientto breathe normally while

you are doing so.


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Global

abdominalenlargement is

usually caused

by air, fluid, orfat.


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Localized

enlargementprobably distend

GB space

occupying lesion,hepatomegaly.


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An aortic aneurysm

Palpable mass

Patient feeling of

pulsation

On rare occasions, alump can be visible.


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An aortic aneurysm

1 in 10 men over 65

may have some

enlargement of the

abdominal aorta.About 1 in 100 will

have a large

aneurysm requiring

surgery.



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(Skin)

Abnormal venouspatterns

Abnormal

discoloration

Umbilicus issunken


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Striae

Stretch marks are a

light silver hue.

Pregnancy and obese

individualsCushings syndrome

(more purple or pink).


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(Skin)

TattoosScars can be drawn

on schematic

diagrams of theabdomen (a picture is

worth a thousand

words).


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Cullens sign

Ecchymosis

periumbilically.

(intraperitonealhemorrhage

ruptured ectopic

pregnancy,hemorrhagic

pancreatitis..)


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Grey-Turners sign

Ecchymosis of

flanks.

(retroperitonealhemorrhage

such as

hemorrhagicpancreatitis)


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Upward flow direction indicates IVC obstruction


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Outward flow pattern from umbilicus in all directions ? Portal HTN


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Evaluate venous return states

Place index finger

side by side over a

vein and press

laterally, milking vein.Release one finger

and time refill, repeat

with other finger.

Venous return is indirection of faster

filling.


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Areas which

become more

pronounced when

the patientvalsalvas areoften associated

with ventralhernias


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Visible Pulsations

More conspicuous in the

thin than in the fat

Greater in the old than in

the young.

Increased in

thyrotoxicosis,

hypertension, or aortic

regurgitation)

In those with an aortic

aneurysm and tortuous

aorta

In those who have a

mass joining the aorta tothe anterior abdominal

wall.


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Visible gastric Peristalsis

Gastric peristalsis is

commonly seen in

neonates with

congenitalhypertrophic pyloric

stenosis

Intestinal peristalsis in

partial and chronic

intestinal obstruction

Colonic obstruction isusually not manifest

as visible peristalsis

Visible intestinal Peristalsis

A f th bd


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Patient's movement

Patients with kidney

stones will frequently

writhe on theexamination table,

unable to find a

comfortable

position

A f th bd


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Patient's movement

Patients with

peritonitis prefer to lie

very still as anymotion causes further

peritoneal irritation

and pain.


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Auscultation


A lt ti


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Auscultation

Bowel sounds

Vascularsounds (bruits)

Friction Rubs


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Auscultation for bowel sounds

It is performed before percussion or

palpation


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Normal sounds are

due to peristaltic

activity.Peristalsis: A

pregressice wavelike

movement that occurs

involuntarily in hollowtubes of the body.


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Compared to the

cardiac and

pulmonary exams,auscultation of the

abdomen has a

relatively minor role.


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Bowel sounds lend

supporting

information to otherfindings but are not

pathognomonicfor any particular

process.

A sc ltation


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Auscultation

1.Diaphragm of

stethoscope

used

2.Skin

depressed to

approximately 1cm

Auscultation


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Auscultation

3.Listening in one

spot is usually

sufficient

4.Listening for15-20or 30-60 seconds

5.Bowel sounds cannot

be said to be absent

unless they are not heardafter listening for3-5

minutes.

Three things about bowel


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Three things about bowel

soundAre bowel sounds

present?

If present, are they

frequent or sparse(i.e.quantity)?

What is the nature of

the sounds

(i.e.quality)?


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Bowel sound decrease

Inflammatory

processes of the

serosaAfter abdominal

surgery

In response to

narcotic analgesics or

anesthesia.


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Inflammation of the

intestinal mucosa

will causehyperactive bowel

sounds.


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Processes which

lead to intestinal

obstruction initially

cause frequentbowel sounds,

referred to as

"rushes."

Auscultation for bowel


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soundsProcesses which lead

to intestinal

obstruction initially

cause frequent bowelsounds, referred to as

"rushes."


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Rushes" means

as the intestines

trying to force

their contents

through a tight

opening.



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soundsRushes" is followed

by decreased sound,

called "tinkles," and

then silence.



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soundsAftersilence the

appearance of bowel

sounds marks the

return of intestinalsounds activity, an

important phase of

the patient's recovery.


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Splash Sign

Splashing sound

indicative ofair or

fluid in body cavitywith shaking

individual: normal in s

stomach.


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Bowel sounds,

then, must be

interpreted within

the context of the

particular clinical

situation.

Bruits


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Bruits

Bruits confined

to systole do notnecessarily

indicate disease.

Auscultation for vascular sounds


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(bruits)

Aortic (midline betweenumbilicus and xiphoid

Renal (two inchessuperiorto and two

inches lateral toumbilicus)

Common iliac (midwaybetween umbilicusand midpoint ofinguinal ligament)



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(bruits)

Presence of a bruit

on the renal artery

would lendsupporting

evidence for the

existence ofrenalartery stenosis.



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(bruits)

When listening forbruits, you will need

to press down quite

firmly as the renal

arteries are

retroperitoneal

structures.


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Venous Hum (rare)

Epigastric/umbilicalarea.

Soft humming noises

in systolic/diastoliccomponent.

Indicates collateral

between portal and

venous systems as inhepatic cirrhosis.


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RubsRubs-Rubs

Liver

SpleenCardiac

Pulmonary


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Friction rubs (rare)

Right and left upperquandrants

Grating sound withrespiratory movement

Indicatesinflammation of the

capsule of the liver orspleen (infection orinfarction).


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Percussion



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P i


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Percussion

Technique

LiverSpleen


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P i (t h i )


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Percussion (technique)

Striking hand

should move

only at the wrist,

with only little

more than force

of gravity

P i (t h i )


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Percussion (technique)

Middle fingerofstriking hand

(plexor) should

knock the

pleximeter firmly,

with a strong

note

There are two basic sounds with


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Percussion

Tympanitic(drum-like)

sounds

produced by

percussing over

air filled

structures.



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Percussion

Dull sounds that

occur when a solid

structure (e.g. liver)orfluid (e.g. ascites)

lies beneath the

region being

examined.

E i ti f Li (P i )


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Examination of Liver (Percussion)

Midclavicularline

is noted

Second

intercostal space

is noted

The two solid organs are


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e o so d o ga s a e

percussable in the normal patient

Liver: will be entirelycovered by the ribs.

Occasionally, an edge

may protrude 1-2

centimeter below the

costal margin.

Spleen: The spleen is

smaller and is entirelyprotected by the ribs.

T d t i th i f th li


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To determine the size of the liver

Measure the liverspan by percussing

hepatic dullness from

above (lung) and

below (bowel). A

normal liver span is 6

to 12 cm in the

midclavicular line.



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Start just below theright breast in a line

with the middle of

the clavicle.

Percussion in this

area should

produce a relatively

resonant note.



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Move your handdown a few

centimeters than

you will be overthe liver, which

will produce a

duller soundingtone.

To determine the si e of the li er


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Continuedownward until

the sound

changes onceagain. At this

point, you will

have reached theinferior margin of

the liver.



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Upper margin isnoted by first dull

percussion note

Lower margin isnoted by first

tympanitic note


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To determine the size of the


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liver

The resonant tone produced bypercussion over the anterior chest

wall will be somewhat less drum like

then that generated over the

intestines. While they are both

caused by tapping over air filled

structures, the ribs and pectoralis

muscle tend to dampen the sound.

Examination of Spleen


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p

(Percussion)

Percussion at Castells Spot

Castells Spot identified

Left anterior axillary line identified

Left lower costal margin identified

Percussion at Castells Spot while patient

inhales and exhales deeply

Dull tone indicates

possible splenomegaly

Spleen percussion


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Spleen percussion

Enlarged spleenproduce a dull

tone, in the left

upper quadrantpercussion but

should then be

verified bypalpation.


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Palpation


Abdominal Palpation


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Technique

Light

DeepLiver edge

Spleen tip

Kidneys

AortaMasses

Abdominal palpation


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Abdominal palpation

To palpate fourquadrants

superficially

from LLQcounterclockwise


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Light Palpation

Light Palpation


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Light Palpation

First warm yourhands by rubbing

them together before

placing them on the

patient.

Abdominal wall

depressed

approximately 1 cm

Abdominal palpation


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Abdominal palpation

Use pads of threefingers of one hand

and a light, gentle,

dippingmaneuverto

examine abdomen

Palpation (light)


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Palpation (light)

Any areas of pain ortenderness are

reserved for

evaluation at the end

of the exam

Light Palpation


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Light Palpation

Mostly looking forareas oftenderness

Tenderness is a

physical exam findinga reflex occurs

(muscle splinting,

wide eyes, moaning,

teeth gritting).

Palpation


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Light palpation assesses

Muscle toneCutaneous

hypersensitivity

(suggests peritoneal

irritation)

Palpation


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Light palpation assesses

Presence ofsuperficial

(intramural) masses is

more prominent if

patient raises their

head ,Intra-abdominal

mass is less

prominent if patientraises their head


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Deep Palpation

Palpation (deep)


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Entire palm

Either one- or

two handed

technique is

acceptable

Deep Palpation


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Deep Palpation

Use palmar surface offingers of one hand

(greatest number of

fingers) and a deep,

firm, gentle maneuver

to examine abdomen

Palpation


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Palpation

Palpate deeply with

finger pads (do not

dig in with fingertips)

Deep Palpation


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Deep Palpation

Palpate tender areaslast

Try to identify

abdominal masses or

areas ofdeep

tenderness


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Two handed technique


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Two handed technique

When deeppalpation is difficult,

examiner may

want to use lefthand placed over

right hand to help

exert pressure

Palpation (deep)


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Push as deeply aspatient will allow

without significant

discomfort

Normal structure that may be

l bl


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palpable

Sigmoid colon

Liver

Kidney

Abdominal aorta

Iliac artery

Distended bladder

Gravid and non-

gravid uterus

Xyphoid processspleen

Abdominal mass


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Abdominal mass

Intra abdominalmasses or

enlargements of the

liver, gallbladder or

spleen

Abdominal wall mass

Intra abdominal masses or enlargements of

th li llbl dd l


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the liver, gallbladder or spleen

They will shift downwith inspiration and

back with expiration.

(not true of masses

within the abdominalwall orretroperitoneal

structures).

Aabdominal wall mass


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Aabdominal wall mass

It will become moreevident and palpable

when patient flexes

neck as this contracts

rectus muscles.

Paraumbilical node


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Paraumbilical node


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Abdominal pain andTenderness


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Type of abdominal pain

Visceral pain Somatic pain

Visceral pain


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Visceral pain

This is pain thatarises from an

organic lesion or

functional disturbance

within an abdominalviscus (dull,poorly

localized, and difficult

for the patient to

characterize).

Somatic pain


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Somatic pain

Painful lesion of theskin

Sharp, bright, andwell localized

Indicatesinvolvement ofparietal peritoneumor the abdominal

wall itself

Tenderness


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Tenderness

If there is tendernessdetermine the point of

maximum tenderness

and its distribution

Abdominal muscle spasm


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p

Voluntary guardingTensing abdominalmuscles due topatient anxiety,

ticklishness, ortoprevent palpation toa painful area

Involuntary guardingMuscular spasm or

rigidity due toperitoneal

inflammationMay be localized(early appendicitis )ordiffuse (perforated

bowel)

Board-like rigidity


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Board like rigidity

If abdominal wall ispalpated as obviously

tense, even as rigid

as a board, board-like

rigidity is so called. Iscaused by the spasm

of abdominal muscle

due to peritoneal

irritation.

Differential diagnosis of abdominal

pain


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pain

Spine painAbdominal wall

pain( differentiated by

having the patient

tense his abdominal

muscles, by forcefully

elevating his head

while keeping hisshoulders flat on the

table)


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Liver palpation

Liver palpation

(St d d M th d)


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(Standard Method)

Start in the RUQ,10centimeters below the

rib margin in the mid-

clavicular line

Place left hand

posteriorly parallel to

and supporting 11th &

12th ribs on right.

Standard Method Liver palpation


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p p

Ask the patient to

take a deep breath.

You may feel theedge of the liver press

against your fingers.

Liver palpation

(St d d M th d)


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(Standard Method)

Palpating hand is

held steady while

patient inhales

Liver palpation

(St d d M th d)


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(Standard Method)

Palpating hand islifted and moved

while the patient

breathes out

Liver palpation


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Another method ofpalpating the liveruses the radial borderof the index finger. In

this method theanterior hand isplaced flat on theanterior abdominal

wall with fingersparallel to the costalmargin

Alternate Method Liver palpation


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Is useful when the

patient is obese or

when the examineris small compared

to the patient.

Alternate Method Liver palpation


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Stand by the patient'schest.

"Hook" your fingers

just below the costal

margin and press

firmly.

Hepatomegaly


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g y

More than 1cm belowthe costal margin

An exception is a

congenitally large

right lobe of the liver

Severe, chronic

emphysema


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Pulsation transmitted from aorta Tricuspid valve insufficiency

Hepatojugular reflux sign


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If you press the liver,you will find thedilated jugular veinbecomes more

bulged or distended,as from theenlargement of liverpassive congestionresulted from rightfailure.

Ballotable sign


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Spleen palpation

Spleen palpation


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Seldom palpable innormal adults.

Causes include

COPD, and deep

inspiratory descent ofthe diaphragm.

Spleen palpation


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Support lower left ribcage with left hand

while patient is supine

and lift anteriorly on

the rib cage.

Spleen palpation


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Palpate upwardstoward spleen with

finger tips of right

hand, starting below

left costal margin.

Have the patient take

a deep breath.

Examination of Spleen

(Palpation)


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(Palpation)

Deep technique used

Starting point is RLQ,proceeding to LUQ


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Kidney palpation

Kidney palpation


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Place left handposteriorly just below

the right 12th rib. Lift

upwards.

Palpate deeply with

right hand on anterior

abdominal wall.

Examination of Kidney


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Patient take a deepbreath.

Feel lower pole of

kidney and try to

capture it between

your hands.

Examination of Kidney


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Right kidney may be felt to slip between hands

during exhalation


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Palpation of the Aorta

Examination of Aorta


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Flat palm placed

over the theepigastrium to

locate pulse



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Press down deeply inthe midline above the

umbilicus.

The aortic pulsation is

easily felt on most

individuals.



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Hands then oriented

vertically on either

side of midline with

distal fingers at level

of pulsation; equal

pressure applied until

pulsation is palpated

A well defined, pulsatile mass, greater than

cm across, suggests an aortic aneurysm.



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Lateral width of pulsation is determined by

space between index fingers


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Special exam


Special exam


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Murphys SignMcBurneysPoint

Rovsings SignPsoas Sign

ObturatorSign

Re boundTenderness

Costovertebral

tenderness

Shifting

DullnessFluid wave


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McBurneys Point


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Localized tendernessJust below midpoint

of line between right

anterior iliac crest and

umbilicus.Heel strike, riding

over bumps in road

while driving,

coughing, will

produce pain.

McBurneys Point (Common Causes)


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AppendicitisIncarcerated orstrangulated hernia

Ovarian torsion (twistedFallopian tube)

Pelvic inflammatorydisease

Abdominal abscess

Hepatitis

Diverticular diseaseMeckel''s diverticulum

Rovsings Sign
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Patient will

experience right lower

quadrant pain (in

region of McBurneysPoint) when left lower

quadrant is palpated.

Non-Classical Appendicitis


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Iliopsoas Sign

Obturator Sign

Iliopsoas Sign


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Patient 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 examiners hand on

thigh. If patient has an inflamed retrocecal

appendix this will produce pain

Iliopsoas Sign


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Anatomic basis forthe psoas sign:

inflamed appendix is

in a retroperitoneal

location in contactwith the psoas

muscle, which is

stretched by this

maneuver.

Obturator Sign


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Internally rotate right leg at the hip with the knee

at 90 degrees of flexion. Will produce pain if

Obturator Sign


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Anatomic basis forthe obturator sign:

inflamed appendix in

the pelvis is in contact

with the obturatorinternus muscle,

which is stretched by

this maneuver.

Rebound Tenderness

(For peritoneal irritation)


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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 hasrebound tenderness. [4]

Cost vertebral Tenderness

(Often with renal disease)


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Use the heel of yourclosed fist to strike

the patient firmly

over the

costovertebralangles.

Compare the left

and right sides.


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Warn the patient Patient sit up on the exam table

Shifting Dullness

(For peritoneal fluid)


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Percuss from anterior

abdomen laterally to

outline areas of

dullness noted

Examination for ShiftingDullness


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Patient rolled slightlytoward the examined

side; movement of the

dull point medially is

described as shiftingdullness and

suggests ascites


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Shifting Dullness


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Fluid wave


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abdominal examination.2

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