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8/12/2019 Cs Clinical 04

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Physical Examination of theAbdomen

Angela Therese C. Flores MDDivision of Neonatology

Deptartmen of Pediatrics

Paul L. Foster School of MedicineEl Paso, Tx


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Learning Objectives

Describe 4 essential elements of the

examination of the abdomen

Analyze accuracy of bedside techniques in

diagnosing organomegaly

Perform self-assessment of your clinical skills in

the examination of the abdomen


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Physical Examination

Systematic

Performed methodically and thoroughly

Consideration for the patients comfort and

modesty

Performed repeatedly

Complements information from the historyFosters patient-physician relationship


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Physical Exam of the Abdomen

Equipment

ExaminerOn the right side of the patient

PatientLying flat on bedArms on the sidesAbdomen exposedLegs flat during initially or with pillow under the kneesLegs bent


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Physical Examination of the Abdomen

Inspection

Auscultation

PercussionPalpation


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Inspection

General appearanceWrithing in pain

Renal or biliary colicLying still in bed

PeritonitisPale and sweatingShock from pancreatitis or gastric perforation

Respiratory rate


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INSPECTION

Inspect the abdomenContourStriaeEcchymosis

Grey Turners signFlank discoloration

Massive ecchymosissecondary to hemorrhagicpancreatitis

Cullens signBluish discoloration of theumbilicus secondary tohemoperitoneum of anycause

Surgical scars

Other causes of Turneror Cullens sign

Ruptured ectopicpregnancy Severe trauma Rupture abdominal aorticaneurysm Coagulopathy Any condition withbleeding into theabdomen


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CULLENS SIGN TURNERS SIGN

NEJM


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INSPECTION

Inspect for herniasAsk patient to cough

Inspect the superficial veinsEvaluate the direction of drainage

Place tip of your index fingers on a vein that is orientedcephalad-caudadCompress and slide index fingers apart for about 7-10 cmRemove finger and observe finger the direction of flow

Vena caval obstruction: veins drains toward the headPortal hypertension: dilated veins radiate from theumbilicus


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AUSCULTATION

BruitsFriction rubs

Vascular disease

Loss of bowel soundsIleus

High-pitched, hyperactive soundsIntestinal obstruction


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AUSCULTATION

Motion of air and liquid in the GITUse diaphragm of stethoscope overmidabdomen

Normal bowel sounds occur every 5-10 mins and have high-pitchedsound

Absence of bowel sounds

IleusRushes of low-pitched rumbling soundsHyperperistalsisSuccusion splashObserved in obstruction


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AUSCULTATION

Listen for bruitsEvaluate each quadrantMay occur in stenosis of the renal artery or abdominal aorta

Listen for friction rubsRight and upper left quadrantHepatic and splenic disorder


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PERCUSSION

Liver size

Shifting dullness

Ascites


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PERCUSSION

Evaluate all 4quadrantsPercussion of theliver

Start on the R midclavicularline in the midchest

Percuss downwardsChest: resonantLiver: dull

Upper and lower

borders: 10 cmColon: tympanic


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PERCUSSION

Percussion of the spleenSpleen hidden within the rib cage against the Traubes space

Traubes space defined by:

Superiorly: 6th ribLaterally: anterior axillary lineInferiorly: costal margin

Dullness in Traubes space is observed in splenic enlargement


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PERCUSSION

Rule out ascitesExamine for shifting dullnessTest for fluid wave


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PALPATION

Begin in an area farthest away from the painUse the flat part of the hand or pads of thefingerLift hand from area to areaDifferent techniques

Light palpationDeep palpationLiver palpationSpleen palpation


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LIGHT PALPATION


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DEEP PALPATION


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LIVER PALPATION


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TEST FOR LIVER TENDERNESS


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SPLEEN PALPATION


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Abdominal Aortic Aneurism

HOW SENSITIVE IS PALPATION FORDETECTING ABDOMINAL AORTIC ANEURISM?Aneurysms require surgery if larger than 5cm.Examination for abdominal aortic aneurysm (AAA) hassensitivity of:

82% if patient's girth is under 100 cm (40 inches)

100% if patient's girth is under 100 cm and aneurysm is

over 5 cm52% if patient's girth is 100 cm or moreFink HA et al. The accuracy of physical examination to detect abdominal aortic aneurysm. JAMA 2000; 160(6):833-836.


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Objectives: skills station

Practice the most recommended techniques of

examination of the abdomen

Analyze commonly made mistakes in

examining the abdomen

Comparison of bedside techniques and

ultrasound imaging in the diagnosis of liver and

spleen


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REFERENCES

Simel DL, Rennie Drummond. The rational

clinical examination:evidence-based clinical

diagnosis 2009

Swartz MH. (2010). Textbook of physical

diagnosis:history and examination.

Philadelphia, PA: Elsevier

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