terminal learning objective - jsomtc

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Slide 1JSOMTC, SWMG(A)

SOCMPhysical Exam of the Abdomen

PFN: SOMPYL0S

Hours: 1.5


Terminal Learning Objective Action: Communicate knowledge of “Physical Exam of the Abdomen”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% IAW course standards on the formative quizzes and the Physical Exam Practical Test grade sheet


References

Bickley L, Szilagyi PG. Bates' Guide to Physical Examination and History‐Taking. Lippincott Williams & Wilkins; 2012.

Venes D, Taber CW. Taber's CyclopedicMedical Dictionary. F A Davis Company; 2013.

D'amico DT, Barbarito C. Clinical Pocket Guide for Health and Physical Assessment in Nursing. Prentice Hall; 2015.

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Reason

Hands on physical exams are a “lost art” due to the many imaging procedures that can be done in a hospital. As a SOF medic you will not have that luxury. Learning how to perform a physical exam of the abdomen could save your teammates hours of pain and possibly even his life!


Agenda

Define key terms related to the physical exam of the abdomen

Communicate the inspection, auscultation, percussion, and palpation of the abdomen

Communicate the examination techniques when assessing the liver, spleen, abdominal aorta, and kidneys

Identify normal and possible abnormal findings on an abdominal radiograph


The Key Terms Related to Physical Exam of the Abdomen

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Key Terms

Aerophagia: swallowing air

Anorexia: a loss of appetite

Bruits: an adventitious sound of venous or arterial origin heard on auscultation

Bloating: an abdominal discomfort related to disorders of intestinal motility and intestinal sensitivity to distention


Key Terms

Borborygmi: a gurgling, splashing sound normally heard over the abdominal region; caused by passage of gas through the liquid contents of the intestine

Cholecystitis: an inflammation of the gallbladder, usually caused by obstruction of the biliary ducts by gallstones

Constipation: a decrease or difficulty in the passage of stool or fecal matter


Key Terms

Diarrhea: the passage of fluid or unformed stool

Dyspepsia: nonspecific upper abdominal discomfort, pain, or nausea not attributed to structural abnormality or peptic ulcer disease

Dysphagia: an inability or difficulty to swallow

Dysuria: a painful or difficulty in urinating

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Key Terms

Flatus: the passing of gas

Guarding: a voluntary contraction of the abdominal wall

Hematuria: blood in the urine

Hematochezia: bright red stool

Hematemesis: vomiting of blood

Incontinence: a loss of control, e.g. urine or feces


Key Terms

Icterus (jaundice): a yellowish discoloration of the skin and sclerae from increased levels of bilirubin

Melena: black tarry stools, caused by digested blood in the GI tract

Nocturia: excessive or frequent urination after going to bed


Key Terms

Obstipation: an absence of the passage of gas or feces

Odynophagia: painful (or pain) when swallowing

Polyuria: passage of a large volume of urine in a given period of time

Tenesmus: straining, especially ineffectual and painful straining at stool or urination

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Key Terms & Health History

Common or Concerning Symptoms

Abdominal pain (acute & chronic)

Indigestion, nausea, vomiting including blood, loss of appetite, early satiety

Dysphagia and/or odynophagia

Changes in urinary frequency or habits

Changes in bowel function (Diarrhea and/or constipation)

Jaundice (icterus)



Associated symptoms

Nausea (feeling sick to my stomach)

Recurrent vomiting and/or retching

• Ask about the amount of vomit

• Ask about the type of vomit: food, green‐ or yellow‐colored bile, mucus, blood, coffee‐ground emesis*

Heartburn (often associated with regurgitation)

Dehydration or electrolyte imbalance

Anorexia and/or excessive weight loss



Other symptoms

Dysphagia (difficulty swallowing)

Odynophagia (pain on swallowing)

Change in bowel function

• Use open ended questions like

“How are your bowel movements?”

“Do you have any difficulties?”

• Excessive gas or flatus

Needing to belch or fart

Patients often state they feel bloated

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Key Terms & Health History Quantify and qualify the patient’s pain

Visceral pain: felt when hollow organs forcefully contract or become distended

• Visceral pain is usually gnawing, cramping, or aching and is often difficult to localize

Visceral periumbilical pain may signify early acute appendicitis

• When severe, may be associated with sweating, pallor, N & V, and restlessness

• Solid organs (liver, spleen) may also generate this type of pain when they swell against their capsules (alcoholic hepatitis)


Types of Visceral Pain



Parietal pain: inflammation in the parietal peritoneum

Steady, aching and aggravated by coughing and/or movement (patients will prefer to lie still)

• More severe and usually easily localized (e.g., late appendicitis)

Referred pain: Pain felt at different location than disordered structure.

Multiple sensory fibers from different sources connecting at a single level of the spinal cord make it difficult for the brain to discern the actual origin of the pain (e.g., liver / gallbladder pain usually refers to the right shoulder)

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Types of Referred Pain


The Inspection, Auscultation, Percussion, and Palpation of the

Abdomen


Anatomy of the Abdomen

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Physical Exam Techniques Least Invasive to Most Invasive

IAPP: Inspect, Auscultate, Palpate each quadrant (light, then deep), and Percuss for liver span at MCL

Expose abdomen from xyphoid process to pubic symphysis

• Ensure patient empties their bladder prior to exam

• Make the patient comfortable

• Avoid having long fingernails and warm your hands

• ALWAYS watch the patients’ face for signs of discomfort


Look First…

Inspect

Skin: scars, striae (stretch marks), excessive vein patterns, rashes, ecchymosis, and/or lesions

Umbilicus: contour, location, and bulges

Contour of the abdomen:

• Flat, rounded, protuberant, or scaphoid

• Flanks, inguinal, or femoral bulges

• Symmetry

Visible organs or masses

Signs of peristalsis and/or pulsations


Abdomen Contours

A

C

B

D

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Abnormal?

D

A B

C


Physical Exam Techniques

Assessing for ventral hernias

Ask patient to raise head and shoulders

• Bulge of a hernia will appear

Assessing for abdominal mass

Ask patient to tighten abdominal muscles

• A mass in abdominal wall remains palpable

• An intra‐abdominal mass is obscured with contraction


Ventral hernias

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Auscultation

Always auscultate before palpation and/or percussion

Listen for

• Bowel sounds

Active bowel sounds are ≈5‐34 sounds per min.

Prolonged gurgles of hyperparistalsis(borborygmi)

• Abdominal bruits over the aorta, iliac, renal, and femoral arteries

• Friction rubs over the liver or spleen


Auscultation Landmarks



Light palpation

Start with gentle probing with the hands

• Identify any superficial organs or masses

• Assess for guarding

Voluntary (patient consciously flinches when you touch him)

Involuntary (muscles spasm when you touch the patient, but he cannot control the reaction)

• Palpate with a light, gentle, dipping motion

When moving your hand, raise it off the skin

Move smoothly and feel in all quadrants

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Light palpation (cont’d)

Use relaxation techniques to assess voluntary guarding

• Tell the patient to breathe out deeply

• Tell the patient to breathe through the mouth



Deep palpation

Palpate deeply in all quadrants

• Identify any masses and note their location, size, shape, consistency, tenderness, pulsations, and any mobility

• Correlate palpable findings with percussion notes


Examination Techniques when Assessing the Liver, Spleen,

Abdominal Aorta, and Kidneys

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Special Tests

Assessing for Appendicitis

Check for:

• Guarding/rebound tenderness in RLQ

• Rovsing’s sign

Referred rebound tenderness to RLQ from deep palpation in LLQ

• Psoas sign

The patient flexes his thigh against the examiner’s hand (pain = positive sign)

• Obturator sign

Flex the patient’s thigh and rotate the leg internally at the hip (pain = positive sign)


Special Tests

Palpating the Liver

Techniques

• Using the left hand to support the back at the level of the 11th and 12th rib

• The right hand presses on the abdomen inferior to the border of the liver and continues to palpate superiorly until the liver border is palpated

• Ask the patient to take a deep breath

Can elicit pain in liver or gallbladder disease and also makes it easier to find the inferior border of the liver


Special Techniques

Assessing for Acute Cholecystitis

Murphy’s sign

• RUQ pain with deep palpation during inhalation

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Special Techniques

Palpating the Liver

The “hooking technique” can be helpful when a patient is obese

• Place both hands, side by side, on the right abdomen below the border of liver dullness

• Press in with the fingers and go up toward the costal margin

• Ask the patient to take a deep breath (liver edge should be palpable)


Special Techniques


Special Techniques

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Special Techniques

Percussing the Liver

Percuss over the liver in both the midclavicularline and at the midsternal line

• Midclavicular percussion should be 6–12 cm; longer than this indicates an enlarged liver

• Midsternal line percussion should be 4–8 cm; shorter than this can indicate a small, hard cirrhotic liver


Special Techniques


Special Techniques

Palpating the Spleen

With the left hand supporting the back

With the right hand palpate the abdomen

Generally the spleen cannot be palpated this way, even with deep inspiration

• Palpating a splenic tip may indicate splenomegaly

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Special Techniques


Special Techniques

Palpating the Abdominal Aorta

Mid‐way between umbilicus and xiphoid process

Just left of midline

Should not exceed 3cm


Special Techniques

Assessing for Ascites

A protuberant abdomen with bulging flanks is suspicious for ascites

• Percuss for areas of tympany and dullness

• Due to gravity, dullness should be located along the lateral sides of the abdomen, while the anterior portion should be tympanic

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Special Techniques

Ascites: shifting dullness

After mapping out the areas of tympany and dullness, have the patient roll to one side

Remap the areas of tympany and dullness

In ascites, there should be a shift due to free fluid moving with gravity


Special Techniques

Ascites: fluid wave

Have the patient or an assistant press hands firmly down the midline

• The pressure stops the transmission of the wave through fat tissue

Tap on one flank sharply and feel with your hand

• Positive if the wave transmits to the other side of the flank


Recording Abdominal Physical Exam Findings

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Recording the Physical Examination

Example

“Abdomen is protuberant with active bowel sounds. It is soft and nontender; no palpable masses or hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness.”


Recording the Physical Examination

Example

“Abdomen is flat. No bowel sounds heard. It is firm and boardlike, with increased tenderness, guarding, and rebound in the right midquadrant. Liver percusses to 7 cm in the midclavicular line; edge not felt. Spleen and kidneys not felt. No palpable masses. No CVA tenderness.”


Normal and Abnormal Findings on an Abdominal Radiograph

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Radiographs


Radiographs


Radiographs

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Questions?


Terminal Learning Objective

Action: Communicate knowledge of “Physical Exam of the Abdomen”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


Reason


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Agenda

Define key terms related to the physical exam of the abdomen

Communicate the inspection, auscultation, percussion, and palpation of the abdomen

Communicate the examination techniques when assessing the liver, spleen, abdominal aorta, and kidneys

Identify normal and possible abnormal findings on an abdominal radiograph


Reason



Break

Some people have dreams, some people strive to crush those dreams…

terminal learning objective - jsomtc

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