Abdominal & Rectal Examinations - Stasio

Question 1

Visceral Pain (colic pain)

Answer 1

• Source is usually hollow organ caused by distension or stretching (intestinal, renal, ureteral)
• Comes and goes, crescendo/decrescendo pattern
• Not well localized

Question 2

Parietal Pain

Answer 2

• Caused by inflammation of the peritoneum
• Steady aching pain that is usually well localized

Question 3

Referred Pain

Answer 3

• From a distant sight
• Right shoulder: gallbladder
• Left shoulder: spleen
• Back: pancreas or aorta

Question 4

The physical examination of the abdomen and rectum includes:

Answer 4

1. Inspection
2. Auscultation
3. Percussion
4. Palpation
5. Rectal examination
6. Special techniques

• (Always auscultate before you palpate!)

Question 5

How should you expose the abdomen for inspection?

Answer 5

Expose from xiphoid to pubis (Adequate exposure of the abdomen is essential)

Question 6

Considerations during inspection:

Answer 6

• Skin - scars, striae, superficial veins
• Umbilicus - hernia, “Caput medusa”
• Contour - flat, scaphoid, protuberant
• Pulsations or peristalsis

Question 7

Caput Medusae

Answer 7

Dilated cutaneous veins around the umbilicus, seen mainly in the newborn and in patients with cirrhosis

Question 8

Auscultation of the Abdomen

Answer 8

–Listen for bowel sounds before palpation and percussion.
•All 4 quadrants
•RLQ – best place to listen d/t cecum
–Normal bowel sounds – high pitched “tinkle” about every 3-5 seconds.
–No bowel sounds after 2 minutes – report as “absent”.

Question 9

Borborygmi – (bor-bo-rig-me)

Answer 9

–Increased, hyperactive bowel sounds
–Low pitched rumbling
–Hyperperistalsis

Question 10

Abdominal bruits, different locations

Answer 10

A soft sound made by disrupted arterial flow through a narrowed artery

• Aortic – between the umbilicus and xiphoid
• Renal artery – just lateral to the aorta
• Femoral artery – along the inguinal ligament

Question 11

Percussion of the Abdomen

Answer 11

•Helps evaluate the presence of:
–Gaseous distention
–Fluid
–Solid masses
–Size and location of the liver and spleen
•Percuss all 4 quadrants
•Best done with the patient in the supine position

Question 12

Tympany

Answer 12

–Most common percussion note.
–Presence of gas in the stomach and small bowel.

Question 13

Liver Percussion

Answer 13

–Percuss along the right mid-clavicular line from top to bottom.
–Resonant (lungs) to dull (liver) to tympanic (intestine)

Question 14

Fluid Wave in Ascites

Answer 14

Fluid wave – Place patient’s or

assistant’s hand in midline. Tap on

one flank and palpate with the other

hand. An easily palpable impulse

suggests ascites.

Question 15

Shifting Dullness in Ascites

Answer 15

Shifting dullness – percuss the patient on their

back and then their side. Note where the sound

changes from tympany to dull and the shift of the

sound when the patient is turned to the side.

Question 16

Abdominal Palpation (segments)

Answer 16

–Light palpation
–Deep palpation
–Liver palpation
–Spleen palpation
–Kidney palpation
–Rebound palpation

Question 17

Light Palpation

Answer 17

Detect tenderness and areas of muscular spasm or rigidity.

Palpate all 4 quadrants.

Use finger tips with a gentle motion.

Question 18

Deep Palpation

Answer 18

Used to evaluate organ size, abnormal masses, aorta, deep pain etc.

One hand placed on top of the other.

Question 19

Rebound Tenderness

Answer 19

–Evaluates for peritoneal tenderness and inflammation.
–Technique:
•In the suspected area of the abdomen, slowly, gently and deeply palpate.
•Then, quickly remove the palpating hand.
–If the patient experiences pain = “+ rebound tenderness”.
–Rovsing’s sign – referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.

Question 20

Palpating the Liver

Answer 20

Place left hand under the right 11th and 12th rib.

Right hand on the RUQ.

Instruct the patient to breath deeply as the examiner gently presses inward and upward with the right hand.

Can repeat the maneuver.

Question 21

Liver “Hooking Technique”

Answer 21

Stand near the patient’s head.

With both hands “hook” your fingers around the lower right costal margin.

Instruct the patient to breath deeply while gently pulling inward and upward with both hands to palpate the liver.

Question 22

Spleen Palpation

Answer 22

Place left hand under the 11th and 12th ribs.

Place right hand in the LUQ under the costal margin.

Instruct the patient to breath deeply as the examiner gently presses inward and upward.

Repeat the maneuver for deeper palpation.

The spleen is normally not palpated in normal conditions.

Question 23

Palpation of the Aorta

Answer 23

Press firmly and deep in the upper abdomen with two hands.

Normal aorta is 2.5 to 3.0 cm wide.

Question 24

Aortic Aneurysm

Answer 24

Pathologic dilatation of the aorta. Can be associated with a bruit.

Assessed with an ultra sound or CT scan.

Question 25

Palpation of the Kidneys

Answer 25

“Sandwich method”

Place a hand above and below the costal margins just lateral to the midline.

Deep and gentle palpation attempt to palpate the lower pole of each kidney.

The kidneys are normally not palpated under normal conditions.

Question 26

Percussion of the kidneys

Answer 26

With a fist, gently hit the area over the costovertebral angle on each side of the spine.

Pain over a kidney may indicate an inflammatory or infectious process of the kidney.

The examiner may also place a flat hand over the CVA and strike the hand.

+ CVA (costovertebral angle) Tenderness = Lloyd’s sign

Question 27

Every abdominal exam should conclude with a…

Answer 27

…DRE (digital rectal examination)

Question 28

DRE positions

Answer 28

Patient on their back – Modified Lithotomy

Lying on left side – a.k.a. – Sims’ Position

Standing, bent over the exam table

Question 29

Rectal Inspection

Answer 29

Spread the buttocks

Sacrococcygeal and perianal areas

Anus and rectum

Note: Inflammation, excoriations, ulcers, rashes, fissures, fistulas, nodules, hemorrhoids, warts, skin tags, tumors

Question 30

Steps to the DRE

Answer 30

Inform the patient of what is going to happen.

Lubricate your gloved index finger.

Place your finger on the external sphincter and ask the patient to relax the sphincter muscles.

Slowly insert the finger as the sphincter relaxes as far as possible.

Question 31

Rectal examination details

Answer 31

During male exams, evaluate the prostate.

Rotate your hand to palpate as much of the rectal surface as possible.

Gently withdraw the glove and note the color.

of the fecal material and test for occult blood.

Note: nodules, irregularities, masses, tenderness,

induration.

Question 32

Fecal Occult Blood Testing

Answer 32

Patients with a positive FOBT require

a through evaluation for CRC.

Colonoscopy is the study of choice.

Sigmoidoscopy and air contrast barium

enema are acceptable alternatives.

Question 33

Examples of Rectal Pathology (…I’ll hold off on the pictures here)

Answer 33

• Anal warts (Condyloma acuminata from HPV; Condylomata lata from syphilis)
• Prolapsed internal hemorrhoid
• Rectal CA

Question 34

Abdominal documentation example

Answer 34

–Flat, + RLQ 4 inch surgical scar
–BS x 4, neg. aortic or femoral bruits
–Tympanic percussion, neg. distension, liver 9 cm
–Neg. tenderness or masses to superficial and deep palpation, aorta not enlarged
–Neg. hepatosplenomegaly (HSM)or tenderness
–Neg. CVA tenderness
–Rectal: neg. external lesions, good sphincter tone, no masses or tenderness, stool for occult blood negative

Question 35

APPENDICITIS

Answer 35

•Etiology
–Obstruction of the appendicular lumen. Fecal or foreign matter, tumors or lymphomas.
•History
–Pain starts peri-umbilical then shifts to the right lower quadrant.
–Nausea and vomiting
–Anorexia
–Fever

Question 36

APPENDICITIS

Answer 36

•Physical Exam
–RLQ pain and RLQ rebound tenderness
–Decreased or absent bowel sounds
–Rovsing’s sign – referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.
–Psoas sign – turn patient on left side and extend the right leg to check for psoas muscle inflammation.
–Obturator sign – place the right leg in a “figure 4”. Press on the right knee while holding down the left iliac crest.
–Always do a rectal examination and a pelvic exam on a female.

Question 37

APPENDICITIS WORK-UP

Answer 37

INCLUDES:
–CBC – moderate leukocytosis with left shift.
–Urine – may contain a few WBC or RBC. Helps R/O any GU condition.
–Plain x-ray – rarely helpful.
–Ultrasound – enlarged and thick walled appendix.
–CT scan – most sensitive. 90 – 98% sensitive.
–Female patient – Must do a pregnancy test to R/O ectopic pregnancy.
–BMP – evaluate electrolytes and renal functions, especially if patient has been vomiting.

Question 38

Acute Cholecystitis

Answer 38

•Etiology
–Obstruction of the cystic duct usually by a gallstone, sometimes a neoplasm.
•History
–RUQ postprandial pain. Biliary colic pain.
–Pain radiating to the right shoulder.
–Nausea and vomiting.
–Anexoria
–Obesity
–Fever
–The 5 “f’s” – female, fat, fertile, fair, flatulent.

Question 39

Acute Cholecystitis

Answer 39

•Physical Examination
–RUQ pain and RUQ rebound tenderness.
–Decreased or absent bowel sounds.
–Abdominal distention.

–Diagnostic Triad – RUQ pain, fever and leukocytosis.

Question 40

Murphy’s sign

Answer 40

RUQ pain and sudden arrest of inspiration during palpation of the liver and gallbladder.

Question 41

Cholecystitis Work-Up

Answer 41

–CBC – leukocytosis with left shift
–Serum bilirubin – can be mildly elevated.
–AST/ALT – can be elevated.
–Ultrasound – will detect stones, thicken GB wall, dilated bile duct and fluid.
–HIDA scan – radionuclide biliary scan.
–CT scan