Abdominal Physical Exam

Question 1

Order of the 4 major components of the physical exam

Answer 1

(1) Inspection
(2) Auscultation
(3) Percussion
(4) Palpation

-do auscultation first b/c mechanical stress to the intestines may disturb activity/bowel sounds

Question 2

Draping of the abdominal exam

Answer 2

-expose only the area right below the breast to the pelvic brim

=> cover breast and everything below pelvic brim to retain modesty

Question 3

Where should arms/legs be during abdominal exam?

Answer 3

• arms/hands down by side

- if abdomen is tensed, have pt bend their knees to relax their stomach

Question 4

General: What to look for upon inspection of the abdomen

Answer 4

• flat vs. distended (distention possibly due to air, fat, or fluid)
• scars
• any skin abnormalities
• organomegally
• ventral hernias: distinguishable b/c become more pronounced via Valsalva maneuver
• pt’s movement: staying still (ex: periotnitis) vs. writhing (ex: kidney stones)

Question 5

Describe a pt’s movement- distinguish staying very still vs. writhing

Answer 5

Pt w/ peritonitis (inflammation of the serosa = lining of the abdominal organs) often stays very still b/c any movement may irritate peritoneal
-ex: appendicitis, cholecystitis

Writhing/squirming- can’t find a comfortable position, may be indicative of kidney stones

Question 6

Typical writeup of inspection on abdominal exam

Answer 6

Flat/distended abdomen, no scars

-can give pertinent negatives of liver failure if clinical picture warrants such as no striae, dilated veins, spider angiomata, caput medusa

Question 7

Describe the technique of abdominal auscultation

Answer 7

• listen in each of the 4 quadrants for about 10-15 seconds

- not rlly pathognomonic for anything, just to see if they are present and describe quantity/quality

Question 8

Some causes of absent or hypoactive bowel sounds

Answer 8

• several days after surgery it is common for bowel sounds not to be present => landmark of recovery is the reappearance of bowel sounds
• late stage of an obstruction when nothing can move past the obstruction
• peritonitis (inflammation of the serosa) can result in a quiet abdomen

Question 9

Describe the progression of bowel sounds in a early to late bowel obstruction

Answer 9

• starts w/ rushes of content rushing past a slightly stenosed opening
• twinkling when just fluid can get past the obstruction
• finally when nothing can get thru the obstruction => silence = absence of bowel sounds

rushes –> twinkles –> silence

-know treatment of obstruction has been successful when you hear reappearance of bowel sounds

Question 10

Some causes of hyperactive bowel sounds

Answer 10

-inflammation of intestinal mucosa such as seen in IBD or diarrhea

Question 11

Where and how do you listen for renal artery bruits?

Answer 11

Listen a few cm above the umbilicus on the lateral edges of the rectus muscle on both sides

Listen w/ the diaphragm, press firmly and deeply since the renal arteries are retroperitoneal structures

Question 12

What are renal artery bruits indicative of?

Answer 12

Indicative of renal artery stenosis- b/c bruit sound is created by the turbulent flow of blood thru a stenosed renal artery

Question 13

General: what to listen for upon auscultation of the bowel

Answer 13

• listen for quantity and quality of bowel sounds

- listen for renal artery bruits laterally a bit above the umbilicus

Question 14

Example of abdominal auscultation write up

Answer 14

ex: Bowel sounds normal, no renal bruits noted
ex: Hyperactive bowel sounds noted in LLQ

Question 15

General: what you’re percussion for on the abdominal exam

Answer 15

• liver edge to look for enlarged liver
• air-fluid level to test for ascites (if warranted)
• all 4 quadrants to note tympanitic vs. dull sounds (if warranted)
• from RLQ diagonally up towards left rib edge if suspecting enlarged spleen

Question 16

Describe how to percuss the liver

Answer 16

For top border: Start midclavicularly right below the right breast and percuss downwards until you hear tympanic (over lungs) to dull (over liver)

For the inferior margin of the liver: keep percussing until it goes from dull (liver) to tympanic (bowel)

Question 17

Technically does percussing over the lungs or intestines make a more tympanitic sound?

Answer 17

Both are air-filled => gives ‘drum-like’ tympanitic sound

-sound over the lungs are dampened by the pectoralis muscle and ribs => less tympanitic over the lungs than over the intestines

Question 18

How may COPD cause an abnormality on percussion of the abdominal exam?

Answer 18

COPD- may have hyperinflation of the lungs depending on the degree of air trapping in the lungs

hyperinflation of the lungs push down the liver => low inferior margin of the liver but not due to hepatomegaly

Question 19

Describe how to assess for ascites via

(a) percussion
(b) palpation

Answer 19

Assessing for ascites via

(a) percussion by testing for shifting dullness- see if the air-fluid level rises when the pt lies on his/her side
(b) palpation by assessing for fluid wave- have pt put hand at umbilicus, tap on one side and feel for wave on the opposite side

Question 20

Describe how to assess air-fluid level

Answer 20

“shifting dullness”

Start percussion at the umbilicus and move laterally, should be equidistant on each side
-air is less dense than water

=> fluid-air level will rise when the pt moves on his/her side
-have the pt lie on their side then re-percuss and see if the air-fluid level rises

If negative shifting dullness => abdominal distention not due to fluid (may be fat or gas)

Question 21

General: what are you palpating for on the abdominal exam

Answer 21

Palpating light then deeper
-assessing for pain, tenderness, rebound, guarding

• palpating for solid structures: liver and spleen
• measuring width (or just feeling for) abdominal aorta
• check CVAT if any indication of kidney inflammation (fever, urinary tract symptoms, back pain)
• look for any masses

Question 22

Where do you start palpation of the abdominal exam?

Answer 22

RUQ or in the quadrant farthest away from the pain.

RUQ –> LUQ –> LLQ –> RLQ

Question 23

What are you palpating for in each quadrant of the abdomen?

Answer 23

All: palpating for any pain, tenderness, rebound, or guarding

RUQ:
-palpating for liver edge: try hook or inhale technique

LUQ:
-palpating for enlarged spleen (start at the umbilicus and palpate upwards towards the left rib angle)

LLQ:
-stool-filled sigmoid colon

RLQ:
-stool-filled cecum

-bladder or pregnant uterus may be palpable

Question 24

Maneuver to make it easier to feel the liver edge

Answer 24

Have the pt take and hold a big inhale b/c the downward mov’t of the diaphragm will push down the liver

Question 25

What is a way on abdominal exam to test for renal inflammation?

Answer 25

CVAT = costavertebral angle tenderness

• pound gently w/ bottom fo fist on the CVA => this will cause pain if the kidney is inflamed
• CVA = where the last ribs articulate w/ the vertebral column

Question 26

How to measure the width of the abdominal aorta?

Answer 26

First feel for the abdominal aorta pulse by pushing down deeply w/ entire hand over the umbilicus. If you can feel pulsation, estimate size by using both thumbs pointing up towards the pts head on either edge of the pulsating structure

Question 27

Example of abdominal palpation write up

Answer 27

ex: soft, non-tender abdomen; no guarding or rebound; liver palpable 2 cm below the right costal margin, spleen not palpable, no masses
ex: tender abdomen, positive Murphy’s sign,

Question 28

How to examine a pt for abdominal pain on palpation

Answer 28

Watch their face while examining the suspected tender area

Question 29

Clinical signs of hyperbilirubinemia

Answer 29

Liver cannot conjugate or secrete bilirubin => high bilirubin in serum

• icterus = yellowing of sclera (eyes)
• jaundice = yellowing of skin
• bilirubinemia = yellow/browning of urine

Question 30

How can cirrhosis cause ascites?

Answer 30

-Portal HTN => fluid backs up into interstitial space due to increase in abdominal capillary hydrostatic pressure

Question 31

Clinical signs of increased systemic estrogen levels

Answer 31

Seen in cirrhosis when liver cannot breakdown estrogen precursors

• gynecomastia (breast development)
• spider angiomata: estrogen causes dilation of arterioles
• testicular atrophy

Question 32

Where are spider angiomatas most visible?

Answer 32

Skin of the upper chest

Question 33

How can cirrhosis cause lower extremity edema?

Answer 33

Liver loses its synthetic ability to produce albumin => hypoalbuminemia => low oncotic pressure in dependent capillaries

Question 34

Describe two clinically relevant manifestations of varices (and how they present)

Answer 34

Varices = when portal HTN causes blood to use collateral circulation to bypass the liver to get back to the heart from the portal vein

(i) most common = esophageal varices
- may present w/ emesis (vomiting up blood) if they rupture => blood in the esophagus

(ii) less common = caput medusa (looks like snakes) when the umbilical vein is recanalized and the blood pushes thru the superficial veins of the abdominal wall which dilate and become visible

Question 35

Which is more common- esophageal or umbilical varices?

Answer 35

Esophageal varices are more common (or more likely to come before) caput medusa

Question 36

Rebound tenderness

Answer 36

• pain is worse upon lifting up hands after applying pressure
• indicative of peritoneal pain

Question 37

Rosving’s sign

Answer 37

-press away from the tenderness (press on the LLQ) and the pt feels pain in the affected area (RLQ) when you lift your hand

= gentler way of assessing rebound tenderness

Question 38

Psoas sign

Answer 38

• have pt press their entire hand against your hand’s resistance => pain
• indicative of appendix inflammation

Question 39

Obturator sign

Answer 39

• pain upon passive flexion and rotation of the patient’s hip (which causes stretching of the obturator muscle)
• indicative of appendix inflammation

Question 40

Which maneuvers can be helpful to assess for appendicitis?

Answer 40

• Rovsing’s sign
• rebound tenderness in RLQ (at McBurney’s point)
• psoas and obturator sign

Question 41

Which clinical findings are rare but indicative of acute pancreatitis?

Answer 41

Grey-Turner’s and Cullen’s sign- both indicative of pancreatic necrosis w/ retroperitoneal or intraabdominal bleeding => indiactive of acute pancreatitis

Question 42

Which maneuvers can be helpful to assess for cholecystitis?

Answer 42

Murphy’s sign

Question 43

Murphy’s sign

Answer 43

pushing towards the liver at the right costal margin causes pain and inspiratory pause/gasp
-indicative of cholecystitis (inflammation of the gall bladder)

Question 44

Grey-Turner’s sign

Answer 44

• bruised lateral flanks (flanks are the space btwn the last rib and the top of the hip bone)
• uncommon sign of acute pancreatitis

Question 45

Cullen’s sign

Answer 45

• superficial edema and/or bruising around the umbilicus

- possible sign of acute pancreatitis