Abdominal/Renal Exam

Question 1

Auscultation

Answer 1

Bowel sounds - not frequency and character in all 4 quadrants

• normal = 5-35 clicks/gurgles per minute
• abnormal = high pitched, decreased/absent
• decreased = none for 1 minute (post-surgical ileum, peritonitis)
• increased (diarrhea, early bowel obstruction)
• high pitched (early intestinal obstruction)

Vascular sounds - abdominal aorta, iliac, renal and femoral arteries

• listen for bruits (vascular obstruction)
• friction rub (inflammation of peritoneal surface of an organ)
• venous hum (increased collaterals circulation between portal and systemic venous systems)

Question 2

Abdominal Exam Order

Answer 2

Inspect
Auscultate
Percuss
Palpate

Question 3

Percussion

Answer 3

Tympany - majority of abdomen; caused by air-filled viscera

Dullness - flat sound without echoes, heard over solid organs; liver, spleen, fluid in peritoneum, feces

Liver: 6-12 cm at mid-clavicular line on right

Spleen: from ribs 6-10 at mid-axillary line on the left

Question 4

Palpation

Answer 4

General:

• warm hands
• bend patient’s knees to relax abdominal muscles if needed
• examine tender areas last

Light = 1 cm in depth
Moderate = 2-3 cm in depth
Deep = more than 3 cm in depth

Question 5

Rebound Tenderness

Answer 5

Pain upon removal of pressure rather than application of pressure to abdomen

Tests for peritoneal inflammation

Question 6

Guarding

Answer 6

Voluntary or involuntary

Question 7

Rigidity

Answer 7

Abdomen is hard, involuntary reflex

Question 8

Rovsing’s Sign

Answer 8

Pain in RLQ during left-sided pressure

Referred rebound tenderness seen in appendicitis

Question 9

McBurney’s Point

Answer 9

Rebound tenderness of pain 1/3 of distance from ASIS to umbilicus (of 2/3 from umbilicus to ASIS)
May suggest appendicitis/peritoneal irritation

Question 10

Murphy Sign

Answer 10

Palpate deeply under right costal margin during inspiration
Observe pain and/or sudden stop in inspiratory effort
Acute cholecystitis or cholelithiasis

Question 11

Courvoisier’s Sign

Answer 11

Enlarged, non-tender gallbladder secondary to pancreatic disease or cancer

Question 12

Aorta

Answer 12

Palpate just above the umbilicus, slightly to the left of midline
Estimate the width of the aorta (normal = 2-3 cm)
Expected = pulsation in anterior-inferior direction
Unexpected = prominent lateral pulsation and more than 3 cm in diameter

Question 13

Sympathetic Levels

Answer 13

Esophagus - T2-8
Stomach - T5-9
Liver - T6-9
Gallbladder - T6-9
Small Intestine - T9-11
Colon - T10-L2
Pancreas - T5-11
Appendix - T12

Question 14

Parasympathetic Levels

Answer 14

Upper portion: esophagus thru transverse colon - OA, AA (vagus n.)

Lower portion: descending colon, sigmoid, rectum - S2-S4 (pelvic splanchnic n.)

Question 15

Iliopsoas Muscle Test

Answer 15

Flex right hip against resistance
Increased abdominal pain = +
Suggests irritation of psoas m. From inflammation of appendix

Question 16

Obturator Muscle Test

Answer 16

Flex right thigh at hip with knee bent and leg internally rotated
Right hypogastric pain = +
Suggests irritation of obturator m. From inflamed appendix

Question 17

Lloyd Punch/Kidney Punch/Costovertebral Angle (CVA) Tenderness

Answer 17

Gently tapping costovertebral angle (area of back overlying kidney) produces pain
Suggests infection around kidney (perinephric abscess) or polynephritis, or renal stone

Question 18

Heel Strike

Answer 18

Pain could indicate appendicitis

Question 19

Abdominal Quadrants

Answer 19

RUQ
LUQ
RLQ
LLQ

Question 20

Abdominal Regions

Answer 20

Right hypochondriac region
Right lumbar region
Right iliac region
Hypogastric region
Umbilical region
Epigastric region
Left hypochondriac region
Left lumbar region
Left iliac region

Question 21

Test for Ascites

Answer 21

Fluid in peritoneal cavity

Shifting dullness test

• percussion borders of tympany and dullness supine and lateral recumbent
• normal = borders stay the same
• positive test = dullness shifts to dependent side and tympany on top side

Test for fluid wave

• tap one flank
• normal = no impulse felt on other flank
• positive test = impulse transmitted to other flank

Question 22

Abdominal Wall Mass vs. Intraabdominal Mass

Answer 22

Patient raises head and shoulders when supine or strains down

Abdominal wall mass = remains palpable
Intraabdominal mass = no longer palpable, obscured by muscular contraction

Question 23

Ventral Hernia

Answer 23

Lying supine, raise both head and shoulders off table

Positive test = bulge of hernia will usually appear

Question 24

Documenting a Normal Abdominal Exam

Answer 24

Abdomen is soft, nontender, nondistended, bowel sounds heard in all 4 quadrants, no rebound, guarding, rigidity, hepatoplenomegaly, or costovertebral angle tenderness

Abd S/NT/ND/BS+ x 4, no R/G/R, HSM or CVAT

Question 25

Inspection

Answer 25

Skin color/characteristics

• jaundice
• Grey Turner Sign - flank ecchymosis secondary to hemorrhage (hemoperitoneum, acute pancreatitis)
• Cullen Sign - ecchymosis around the umbilicus (preumbilical) secondary to hemorrhage (hemoperitoneum, acute pancreatitis, ectopic pregnancy)
• scars/striae
• dilated veins
• rashes and lesions

Contour/symmetry

• abdominal distension
• hernias/masses

Surface motion - peristalsis
Pulsations