ABDOMINAL ASSESSMENT

Question 1

What should the general approach include?

Answer 1

1. Patient position: Patient is supine on the exam table with arms at sides and leg rest extended
2. Examiner position: Stand to patient’s right side as much as possible; Assess painful area last
3. Draping: Undrape patient’s abdomen from symphysis pubis to just above the xiphoid process.-Use sheet to cover patient below the waist.

Question 2

GENERAL ABDOMINAL INSPECTION:

Answer 2

A. Skin Characteristics (Scars, rash, lesions, color)
B. Venous return patterns
C. Contour/Symmetry: Flat rounded, scaphoid or distended; protrusions
D. Surface Motion/Visible Pulsations: Abnormal movements
E. Umbilicus Placement

Question 3

ABDOMINAL MUSCLE INSPECTION: (Inspect as patient raises head/tries to sit-up)

Answer 3

A. Masses
B. Hernia
C. Separation of Muscles

Question 4

AUSCULTATION: (Note: painful area last).

BOWEL SOUND AUSCULTATION:

Answer 4

A. Listen: Listen for bowel sounds with DIAPHRAGM in all 4 quadrants.
B. NOTE are the sounds normal, hyperactive or hypoactive) frequency of bowel sounds (normally 5-35 per minute).

Question 5

ABDOMINAL BRUIT AUSCULTATION (vascular sounds):

Answer 5

A. Listen for Bruits with Bell: Aorta, renal, iliac, and femoral arteries

Question 6

PERCUSSION: **Percuss painful areas last-Watch patient’s face.
GENERAL ABDOMINAL PERCUSSION:

Answer 6

A. TONE: Percuss in all 4 quadrants for tone (tympany, hyper-resonance, resonance, or dullness)

Question 7

LIVER PERCUSSION:

Answer 7

Percuss the liver borders (down right MCL) to estimate span (normal adult liver span is 6-12 cm)

Question 8

SPLEEN PERCUSSION:

Answer 8

Percuss just posterior to the mid-axillary line of the patient’s left, beginning at areas of lung resonance and moving in several directions-EXPECT SMALL AREA OF DULLNESS FROM 6TH TO 10TH RIB;
Percuss lowest intercostal space in left anterior axillary line before and after patient takes a deep breath-EXPECT TYMPANY BEFORE AND AFTER DEEP BREATH.

Question 9

GASTRIC AIR BUBBLE PERCUSSION:

Answer 9

Percuss in area of left lower anterior rib cage and left epigastric region-EXPECT TYMPANY OF GASTRIC AIR BUBBLE (LOWER THAN INSTESTINE TYMPANY)

Question 10

PALPATION: Bend patinet’s knees; Do painful area and rebound tenderness tests last; Watch patient’s face
LIGHT PALPATION:

Answer 10

Use palmar surface of fingers, depress abdominal wall up to 1 cm with light, even circular motion in all 4 quadrants

Question 11

THINGS TO NOTE WITH PALPATION:

Answer 11

A. Muscular resistance
B. Tenderness
C. Masses **Using same hand position as light palpation, apply MODERATE PRESSURE as an intermediate step to gradually approach deep palpation

Question 12

DEEP PALPATION:

Answer 12

Palpate with two hands, pressing 2-4 cm deep

Question 13

WHAT TO NOTE WITH DEEP PALPATION:

Answer 13

A. Umbilicus & Umbilical Ring: Bulges, masses
B. Liver Border In Right Costal Margin: LIVER HOOKING (alternative technique)
C. Gallbladder: MURPHY’S SIGN-See Advanced Skill Section
D. Spleen In Left Costal Margin
E. Right & Left Kidneys
F. Aortic Pulsation In Midline: Expect anterior direction
G. Other Masses

Question 14

ADVANCED SKILLS FOR ABDOMINAL ASSESSMENT:

Answer 14

A.  RUQ ABDOMINAL PAIN/MURPHY'S SIGN TESTING
B.  REBOUND TENDERNESS TESTING: BLUMBERG SIGN
C. RLQ ABD. PAIN TESTING:
       McBURNEY SIGN
       ROVSING SIGN
       ILIOPSOAS MUSCLE TEST
       OBTURATOR MUSCLE TEST
E. MARKLE (HEEL JAR) TEST

Question 15

RUQ ABDOMINAL PAIN/MURPHY’S SIGN TESTING

Answer 15

palpation of gallbladder for cholecystitis

Question 16

REBOUND TENDERNESS TESTING: BLUMBERG SIGN

Answer 16

deep palpation of abdomen for peritoneal irritation; appendicitis

Question 17

RLQ ABD PAIN: McBURNEY SIGN

Answer 17

Rebound tenderness associated with appendicitis at McBurney’s point (2/3 distance from umbilicus to the right anterior superior iliac spine).

Question 18

RLQ ABD PAIN: ROSVING SIGN

Answer 18

Right lower quadrant pain elicited by palpation of the left lower quadrant in acute appendicitis.

Question 19

RLQ ABD PAIN: ILIOPSOAS MUSCLE TEST

Answer 19

Hand above the right thigh, have the patient lift their right knee up to their chest against the resistance of your hand. If pain with this movement, high likelihood of appendicitis.

Question 20

RLQ ABD PAIN: OBTURATOR MUSCLE TEST

Answer 20

The patient lies on her/his back with the hip and knee both flexed at ninety degrees. The examiner holds the patient’s ankle with one hand and knee with the other hand. The examiner internally rotates the hip by moving the patient’s ankle away from the patient’s body while allowing the knee to move only inward. This is flexion and internal rotation of the hip. Pain with this movement could indicate a ruptured appendix or pelvic abscess.

Question 21

RLQ ABD PAIN: MARKLE (HEEL JAR) TEST

Answer 21

A clinical sign in which pain in the right lower quadrant of the abdomen is elicited by dropping from standing on the toes to the heels with a jarring landing. It is found in patients with localized peritonitis due to acute appendicitis. It is similar to rebound tenderness, but may be easier to elicit when the patient has firm abdominal wall muscles. Abdominal pain on walking or running is an equivalent sign.

Question 22

ASCITES ASSESSMENT: SHIFTING DULLNESS

Answer 22

Percuss across the abdomen as for flank dullness, with the point of transition from tympany to dullness noted.
The patient then is rolled on his/her side away from the examiner, and percussion from the umbilicus to flank area is repeated.
Positive test: When ascites is present, the area of dullness will shift to the dependent site. The area of tympany will shift toward the top.

Question 23

ASCITES ASSESSMENT: FLUID WAVE TEST

Answer 23

Have the patient lying supine.
The patient or an assistant places one or both hands (ulnar surface of hand downward) in a wedge-like position into the patient’s mid abdomen, applying with slight pressure.
The examiner places the fingertips of one hand along one flank, and with the other hand firmly gives a sharp tap along the opposite flank.
Positive test: The examiner is able to detect “a shock wave” of fluid moving against the fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to the other by the force of the tap along the opposite flank.

Question 24

CVA TENDERNESS EXAMINATION: **DO AT END OF EXAM OR WHILE EXAMINING PATIENT’S BACK POSTERIOR LUNGS.

Answer 24

A. Indirect percussion

B. Direct percussion