11. Final Abdominal Examination.ppt

Bahir Dar Univrsity
College of Medicine and Health sciences
Department of Nursing
ABDOMINAL EXAMINATION
By- Yeshaneh Seyoum (Lecturer)
Jan, 2015
Bahir Dar, Ethiopia
7/1/2023 1

OUTLINE OF PRESENTATION
General principles of examination
Landmarks of the abdominal wall
Abdominal anatomy(Quadrants &the organs within)
Inspection, Auscultation
Percussion
Examination of Liver(Percussion)
Examination of spleen(Percussion)
Palpation(Liver, Spleen, Kidney, Aorta)
Special Exams(Murphy’s Sign , McBurney’s Point,
Rovsing’s Sign, Psoas Sign, shifting dullness, etc)
Summary
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Learning Objectives
 Follow the general principles of physical
examination during abdominal examination
 Identify the landmarks of the abdominal wall
 Describe the abdominal quadrants with their organs
 List the step of abdominal examination
 Identify abnormal shape of the abdomen.
 Describe the character and frequency of normal
bowel sounds
 Determine the vertical liver span & technique of
measurement
 Differentiate light and deep palpitation
 List specific signs related to organ pathology
 Perform special examinations in abdominal
examinations
 Recognize tenderness and rebound tenderness
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Important Aspects of Physical
Examination?
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• Wash your hands,
preferably while the
patient is watching
• Washing with soap
and water is an
effective way to
reduce the
transmission of
disease

How to Perform the Physical Examination?
• Exposing only the area
that are being examined
• Take a spare bed sheet
and drape it over their
lower body such that it
just covers the upper
edge of their underwear
• Offer a chaperone for
both sexes.
• Explain what you're
going to do
• Sequential
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Gloves should be worn when..
• Examining any
individual with
exudative lesions or
weeping dermatitis
• When handling blood-
soiled or body fluid-
soiled sheets or
clothing
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General principles of exam
Good light
Relaxed patient
Full exposure of
abdomen from above
the xiphoid process to
the symphysis pubis.
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• Have the patient empty
their bladder before
examination
• Have the patient lie in a
comfortable, flat, supine
position
• Have them keep their
arms at their sides or
folded on the chest
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• Before the exam, ask
the patient to identify
painful areas so that
you can examine those
areas last
• During the exam pay
attention to their facial
expression to assess for
sign of discomfort
• Distract the patient if
necessary with
conversation or
questions.

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• Use warm hand, warm
stethoscope, and have
short finger nails
• Approach the patient
slowly and deliberately
explaining what you
will be doing

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• Stand right side of the
bed
• Exam with right hand
• Head just a little
elevated
• Ask the patient to keep
the mouth partially
open and breathe gently

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• If muscles remain
tense, patient may be
asked to rest feet on
table with hips and
knees flexed

General Principles of Physical
Examination
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• If the patient is ticklish
or frightened
 Initially use the
patients hand under
yours as you palpate
 When patient calms
then use your hands
to palpate.
• Watch the patient’s face
for discomfort.

Question and Answer!
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What principles of physical examination are
you going to follow during abdominal
examination?

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Think Anatomically
• When looking, listening,
percussing and feeling
imagine what
organs live in the area
that you are examining.

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• Costal margin,
umbilicus, iliac
crest, anterior
superior iliac
spine, symphysis
pubis, pubic
tubercle,
inguinal
ligament, rectus
abdominis
muscle, xiphoid
process.
Landmarks of the abdominal wall

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Four quadrants
Abdominal Anatomy
Nine Regions

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Abdominal Anatomy
Right
hypochondriac
region
Left
hypochondriac
region
Right iliac region Left iliac region
Left lumbar region
Right lumbar region

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Seven Abdominal Regions
Epi gastric
region
Umblical region
Hypo gasteric
Reg.
Rt Upper
abd.Reg
Lt Upper abd.
Region
Rt Lower
abd.Reg
Lt Lower
abd.Reg

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Right Upper Quadrant (RUQ)
• Liver,
• Gallbladder,
• Duodenum,
• Head of pancreases
• Right kidney and adrenal
• Hepatic flexure of colon
• Part of ascending and
transverse colon

• The lower margin of the liver, the liver edge, is often
palpable.
• At a deeper level in the RUQ, the lower pole of the
right kidney is occasionally palpable, especially in
thin individuals with relaxed abdominal muscles
• Most of the normal gallbladder lies deep to the liver
and cannot be distinguished from it clinically
• The duodenum and pancreas lie deep in the upper
abdomen, where they are not normally palpable.
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Right Upper Quadrant (RUQ)

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Right Lower Quadrant (RLQ)
• Cecum,
• Appendix
• Right ovary & tube(in
case of female),
• Right ureter
• Part of ascending colon

Right Lower Quadrant (RLQ)
• The cecum and part of the ascending colon
form a softer, wider tube
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Left Lower Quadrant (LLQ)
• Sigmoid colon
• Left ovary & tube(in
case of female)
• Part of descending
colon
• Left ureter

Left Lower Quadrant (LLQ)
• The sigmoid colon is frequently palpable as a firm,
narrow tube
• Portions of the descending colon may also be
palpable
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Left Upper Quadrant (LUQ)
• Stomach,
• Spleen,
• Left lobe of liver
• Left kidney,
• Pancreas (tail),
• Left kidney and adrenal
• Splenic flexure of colon
• Part of transverse and
descending colon

Left Upper Quadrant (LUQ)
• The tip of a normal spleen is palpable below
the left costal margin in a small percentage of
adults
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Epigastric Area
• Stomach,
• Pancreas (head and
body),
• Aorta

Epigastric Area
• Pulsations of the abdominal aorta are
frequently visible and usually palpable in the
upper abdomen
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Question and answer!!
• Tell two landmarks of the abdomen?
• Mention quadrants of the abdomen and the
organs with in?
What is the preferred order of examination
during abdominal examination?
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Physical Examination of the Abdomen
Inspection
Auscultation
Percussion
Palpation
Special Tests
Stand at the patient’s right side and proceed in an
orderly fashion with

INSPECTION
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ABDOMEN: Inspection
There should be adequate exposure of the abdomen for proper inspection. The
patient should be exposed from the inferior chest to the anterior iliac spines
bilaterally.

Contents of inspection
 Abdominal contour/appearance
 Respiratory movement
 Abdominal skin
 Abdominal vein
 Symmetry
 Peristalisis
 Hernial sites
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Abdominal contour/appearance
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Starting from your usual
standing position at the
right side of the bed,
inspect the abdomen.
As you look at the contour
of the abdomen and watch
for peristalsis, it is helpful
to sit or bend down so
that you can view the
abdomen tangentially.

Abdominal contour/appearance
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 Normal – slightly retracted from the xiphoid,
symmetrical, flat
Abdominal localized bulge – mass
Scaphoid – retracted backward – malnutrition
Distension – fluid, air, pregnancy, obesity
Global abdominal enlargement is usually caused by
air, fluid, or fat.

Respiratory Movement
• Abdomen moves with respiration
– Predominantly seen in children and men
• Decreased abdominal movement with respiration
– Peritonitis (acute)
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Appearance of the abdomen(Skin)
Note the skin, including:
 Scars. Describe or diagram their location.
 Striae. Old silver striae or stretch marks are normal.
 Dilated veins. A few small veins may be visible
normally.
 Rashes and lesions
The umbilicus. Observe its contour and location, and any
signs of inflammation or hernia.
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• Abnormal venous
patterns
• Abnormal discoloration
• Umbilicus is sunken

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• Stretch marks are a light
silver hue.
• Pregnancy, chronic
ascites, rapid weight
gain and obese
individuals
• Cushing’s syndrome
(more purple or pink).
Striae

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• Tattoos
• Scars can be drawn on
schematic diagrams of
the abdomen (a picture
is worth a thousand
words).

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Cullen’s sign
• Ecchymosis
periumbilically.
(intraperitoneal
hemorrhage, ruptured
ectopic pregnancy,
hemorrhagic
pancreatitis..)

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Grey-Turner’s sign
• Ecchymosis of
flanks.
(retroperitoneal
hemorrhage such as
hemorrhagic
pancreatitis)

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Abdominal wall veins
• Normally – not seen
– Drain away from the umblicus
– Veins in the upper quadrants drain to SVC
– Veins in the lower quadrants drain to IVC
• During venous obstruction
– Drainage direction will be reversed

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Symmetry
=Is the abdomen symmetric?
• Are there visible organs or masses?
• Look for an enlarged liver or spleen that has
descended below the rib cage.
• Asymmetry due to an enlarged organ or mass.
• Lower abdominal mass of an ovarian or a uterine
tumor.

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How to Check Venous
Drainage
The vein is
emptied between two
fingers to a distance
of a few centimeters,
then allows blood to
refill the vein from
one direction by removing
one compressing finger

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Visible Pulsations
• More conspicuous in the
thin than in the fat
• Greater in the old than in
the young.
• Increased in
thyrotoxicosis,
hypertension, or aortic
regurgitation)
• In those with an aortic
aneurysm and tortuous
aorta
• In those who have a
mass joining the aorta to
the anterior abdominal
wall.

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Peristalsis
Peristalsis. Observe for several minutes if you suspect
intestinal obstruction.
Visible bowel motion on the abdominal surface
Normally peristalsis is not seen but it may be visible
normally in very thin people.
Observed during obstructive conditions
Pyloric stenosis, small bowel obstruction, …
Increased peristaltic waves of intestinal obstruction and
diarrhea.
Direction – LUQ to RLQ

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Hernia
• Hernia the protrusion of an organ or tissue out of the
body cavity in which it normally lies.
• Passage of intra abdominal content via weak
abdominal wall sites
• Hernial sites are:
– Epigastrium, periumblical, inguinal, femoral,
incisional,…
• Examined by asking the patient to strain/cough while
inspecting and palpating the hernial sites

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Question and answer!
• How do you position yourself when you inspect the
contour of the abdomen and peristalsis?
• What is the normal contour of the abdomen?
• Scaphoid contour of the abdomen indicate-------?
• What things do you inspect in the skin of the
abdomen?
• How hernia is examined/ ruled out?

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Auscultation
Bowel sounds
Vascular sounds (bruits)
Friction Rubs

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Auscultation for bowel sounds
It is performed before
percussion or palpation
Auscultation can be
done with the
diaphragm.
You should listen for at
least 10-15 seconds and
note the pitch and
frequency of bowel
sounds. If you do not
hear any bowel sounds,
you should listen for 3-
5 minutes before you
can state that the
patient does not have
any bowel sounds

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• Normal sounds are due
to peristaltic activity.
• Peristalsis: A
pregressice wavelike
movement that occurs
involuntarily in hollow
tubes of the body.

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• Compared to the
cardiac and
pulmonary exams,
auscultation of the
abdomen has a
relatively minor role.

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1. Diaphragm of
stethoscope used
2. Skin depressed to
approximately 1 cm
3. Listening in one spot
is usually sufficient
4. Listening for 15-20 or
30-60 seconds

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5. Bowel sounds cannot be
said to be absent unless
they are not heard after
listening for 3-5
minutes.
 Listen for bowel sounds
and note their frequency
and character.
 Normal sounds consist
of clicks and gurgles,
occurring at an estimated
frequency of 5 to 34 per
minute.

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Three things about bowel sounds
1. Are bowel sounds
present?
2. If present, are they
frequent or sparse
(i.e.quantity)?
3. What is the nature of
the sounds
(i.e.quality)?
Abnormal findings of BS
Absent
Bowel obstruction,
Peritonitis,
Paralytic ileus.
Low Potassium
Surgical manipulation
Increased Bowel sounds
Increased motility of
fluids
Diarrhea

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Bowel sound Decrease
• Inflammatory
processes of the serosa
• After abdominal surgery
• In response to narcotic
analgesics or anesthesia.

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• Inflammation of the
intestinal mucosa
will cause
hyperactive bowel
sounds.

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• Processes which lead to
intestinal obstruction
initially cause frequent
bowel sounds, referred
to as "rushes."

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• “Rushes" means as
the intestines trying
to force their
contents through a
tight opening.

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• “Rushes" is followed
by decreased sound,
called "tinkles," and
then silence.

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• After silence the
appearance of bowel
sounds marks the
return of intestinal
sounds activity, an
important phase of
the patient's
recovery.

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Splash Sign
• Splashing sound
indicative of air or
fluid in body cavity
with shaking
individual: normal
in s stomach.

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• Bowel sounds, then,
must be interpreted
within the context of
the particular
clinical situation.

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Bruits
• Bruits confined to
systole do not
necessarily indicate
disease.

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Auscultation for vascular sounds (bruits)
Aortic (midline between
umbilicus and xiphoid)
Renal (two inches
superior to and two
inches lateral to
umbilicus)
 Common iliac (midway
between umbilicus and
midpoint of inguinal
ligament)

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Auscultation for vascular sounds (bruits)
• Presence of a bruit
on the renal artery
would lend
supporting evidence
for the existence of
renal artery
stenosis.

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Auscultation for vascular sounds
(bruits)
• When listening for
bruits, you will need to
press down quite
firmly as the renal
arteries are
retroperitoneal
structures.

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Rubs –Rubs-Rubs
• Liver
• Spleen
• Cardiac
• Pulmonary

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Friction rubs (rare)
• Right and left upper
quandrants
• Grating sound with
respiratory movement
• Indicates inflammation
of the capsule of the
liver or spleen
(infection or
infarction).

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Percussion
• Technique
• Liver
• Spleen
(Please See the techniques of percussion in the previous lesson notes )

• Percussion helps you to assess the amount and
distribution of gas in the abdomen and to
identify possible masses that are solid or fluid
filled.
• Percuss the abdomen lightly in all four
quadrants to assess the distribution of tympani
and dullness.
• A protuberant abdomen that is tympanitic
throughout suggests intestinal obstruction.
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Percussion

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There are two basic sounds with Percussion
• Tympanitic (drum-
like) sounds
produced by
percussing over air
filled structures.

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There are two basic sounds with Percussion
• Dull sounds that
occur when a solid
structure (e.g. liver)
or fluid (e.g. ascites)
lies beneath the region
being examined.

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The two solid organs are percussable in
the normal patient
• Liver: will be entirely
covered by the ribs.
Occasionally, an edge
may protrude 1-2
centimeter below the
costal margin.
• Spleen: The spleen is
smaller and is entirely
protected by the ribs.

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Examination of Liver (Percussion)
• Midclavicular line is
noted
• Second intercostal
space is noted

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To determine the size of the liver
• Measure the liver span
by percussing hepatic
dullness from above
(lung) and below
(bowel). A normal liver
span is 6 to 12 cm in the
midclavicular line.
4-8 cm in
Midsternal
line
6-12 cm from right
mid clavicular line
Normal liver
span

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• Start just below the
right breast in a line
with the middle of the
clavicle. Percussion in
this area should
produce a relatively
resonant note.

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• Move your hand down
a few centimeters then
you will be over the
liver, which will
produce a duller
sounding tone.

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• Continue
downward until the
sound changes
once again. At this
point, you will
have reached the
inferior margin of
the liver.

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Examination of Liver (Percussion)
• Upper margin is noted
by first dull percussion
note
• Lower margin is noted
by first tympanitic note

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• The resonant tone produced by
percussion over the anterior chest wall
will be somewhat less drum like than that
generated over the intestines. While they
are both caused by tapping over air filled
structures, the ribs and pectoralis muscle
tend to dampen the sound.

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Examination of Spleen(Percussion)
• When a spleen enlarges, it expands anteriorly,
downward, and medially, often replacing the
tympany of stomach.
• It then becomes palpable below the costal margin.
• Percussion cannot confirm splenic enlargement but
can raise your suspicions of it.
• Palpation can confirm the enlargement, but often
misses large spleens that do not descend below the
costal margin.

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• Two techniques may help you to detect
splenomegaly/ an enlarged spleen:
1. Percuss the left lower anterior chest wall
between lung resonance above and the costal
margin (an area termed Traube’s space).
• Dullness raises the question of splenomegaly.

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Mid axillary line
Normal
spleen
Enlarged
spleen
Anterior axilary line

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2. Check for a spleenic percussion sign.
• Percuss the lowest inter space in the left
anterior axillary line, as shown below. This
area is usually tympanitic.
• Then ask the patient to take a deep breath, and
percuss again. When spleen size is normal, the
percussion note usually remains tympanitic.

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• A change in percussion note from tympany to
dullness on inspiration suggests splenic
enlargement.
This is a positive splenic percussion sign.

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NEGATIVE SPLENIC PERCUSSION SIGN POSITIVE SPLENIC PERCUSSION SIGN
Inspiratory
movement

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Percussion at Castell’s Spot
• Castell’s Spot identified
Left anterior axillary line identified
Left lower costal margin identified
• Percussion at Castell’s Spot while patient
inhales and exhales deeply
Dull tone indicates possible
splenomegaly

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Spleen percussion
• Enlarged spleen
produce a dull tone,
in the left upper
quadrant
percussion but
should then be
verified by palpation.

Summary – Reflective
1. What is the preferred order for examination of
the abdomen?
2. When do you say a bowel sound is absent?
3. Differentiate hypoactive, normoactive and
hyperactive bowel sounds?
4. Describe two conditions in which the bowel
sound is absent?
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Palpation
Abdominal examination
What is palpation?
What are the techniques of palpation?

A. Liver edge
B. Spleen
edge
C. Rovsing’s
sign
D. Psoas sign
E. Obturator
sign
1. Palpable deep to the left costal margin during
inspiration
2. Palpable below the right costal margin in the
midclavicular line during inspiration
3. Pain elicited when the patient’s right thigh is
flexed at the hip with the knee bent, and the leg
is internally rotated at the hip
4. Examiner’s hand is placed on the patient’s right
knee and the patient is asked to raise his or her
right thigh against the examiner’s hand
5. Pain elicited by gently picking up a fold of
abdominal skin anteriorly
6. Pain in the right lower quadrant during palpation
of the left lower quadrant
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Active Listening Exercise
Matching

Abdominal Palpation
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Technique
• Light
• Deep
• Bimanual
• Liver edge
• Spleen tip
• Kidneys
• Aorta
• Masses

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Abdominal Palpation
Light Palpation

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Abdominal Palpation
• To palpate four
quadrants superficially
from LLQ
counterclockwise
• Is used to evaluate
general condition,
nature of any distention,
and gross abnormalities
and painfulness.

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Light Palpation
Begin with light palpation.
At this point you are mostly looking for areas
of tenderness
Voluntary or involuntary guarding may also be
present
The most sensitive indicator of tenderness is
the persons facial expression
So - watch the person's face, not your
hands!!

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Light Palpation
First warm your hands
by rubbing them
together before placing
them on the patient.
 Abdominal wall
depressed
approximately 1-2 cm

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Abdominal Palpation
Keeping your hand and
forearm on a horizontal plane,
with fingers together and flat
on the abdominal surface,
palpate the abdomen with a
light, gentle, dipping
maneuver
Feeling the abdomen gently
is especially helpful in
identifying abdominal
tenderness, muscular
resistance, and some
superficial organs and
masses

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Light Palpation
• Any areas of pain or
tenderness are reserved
for evaluation at the
end of the exam
• Mostly looking for
areas of tenderness
• Tenderness is a
physical exam finding
a reflex occurs (muscle
splinting, wide eyes,
moaning, teeth
gritting).

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Light Palpation
• Identify any area of
increased resistance to
your hand.
• If resistance is present,
try to distinguish
voluntary guarding
from involuntary
muscular spasm.
• Involuntary rigidity
(muscular spasm)
typically persists despite
these maneuvers.
 It indicates
peritoneal
inflammation.
1. Try all the relaxing methods you
know
2. Feel for the relaxation of
abdominal muscles that normally
accompanies exhalation.
3. Ask the patient to mouth-breathe
with jaw dropped open.

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Light Palpation
Light palpation assesses
• Presence of superficial
(intramural) masses is
more prominent if
patient raises their
head, intra-abdominal
mass is less prominent
if patient raises their
head Next palpate deeply to detect large masses or tenderness

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Deep Palpation
This is usually required
to detect any organ
enlargement,
abdominal masses or
swellings
Entire palm
Either one- or two
handed technique is
acceptable
Use one hand on top of
another and push down
slowly.
TWO-HANDED DEEP PALPATION

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Deep Palpation
• Use palmar surface of
fingers of one hand
(greatest number of
fingers) and a deep,
firm, gentle maneuver
to examine abdomen
One handed technique

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Deep Palpation
• Palpate deeply with
finger pads (do not “dig
in” with finger tips)

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Deep Palpation
• Palpate tender areas
last
• Try to identify
abdominal masses or
areas of deep
tenderness

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Deep Palpation
• Push as deeply as
patient will allow
without significant
discomfort

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Normal structure that may be palpable
• Sigmoid colon
• Liver
• Kidney
• Abdominal aorta
• Iliac artery
• Distended bladder
• Gravid and non-
gravid uterus
• Xyphoid process
• Spleen

Palpation!
Discuss in pair and share for all!
• Differentiate the techniques of light and deep
palpation?
• How do you differentiate voluntary rigidity
from involuntary rigidity during abdominal
palpation?
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Intra abdominal masses or enlargements of
the liver, gallbladder or spleen
• They will shift down
with inspiration and
back with expiration.
(not true of masses
within the abdominal
wall or retroperitoneal
structures).

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Liver Palpation (Standard Method)
• Start in the RUQ,10
centimeters below
the rib margin in
the mid-clavicular
line
• Place left hand
posteriorly parallel
to and supporting
11th & 12th ribs on
right.

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Standard Method Liver palpation
• Ask the patient to
take a deep breath.
• You may feel the
edge of the liver
press against your
fingers.

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• Palpating hand is
held steady while
patient inhales
• Palpating hand is
lifted and moved
while the patient
breathes out

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Liver Palpation
Note any tenderness. If
palpable at all, the edge of a
normal liver is soft, sharp, and
regular, its surface smooth.
Firmness or hardness of the
liver, bluntness or rounding of
its edge, and irregularity of its
contour suggest an abnormality
of the liver.
On inspiration, the liver is
palpable about 3 cm below the
right costal margin in the mid
clavicular line
Large irregular liver
Large smooth liver

7/1/2023 121
Hepatomegaly
• More than 1cm below
the costal margin
• An exception is a
congenitally large
right lobe of the liver
• Severe, chronic
emphysema

7/1/2023 122
Standard Method of Liver palpation

7/1/2023 123

7/1/2023 124
Hooking Technique
This is helpful, especially when the patient is obese.
Hooking procedure
Stand to the right of the patient’s chest
Place fingers curved under the rib cage
Have patient inhale
Feel the border of the liver descend to your
fingers
Note smoothness, or nodules
Tenderness over the liver suggests inflammation, as in
hepatitis, or congestion, as in heart failure.

7/1/2023 125
Hooking Technique
The liver edge shown below is palpable
with the finger pads of both hands.

7/1/2023 126
Liver palpation(Qs &As)
Describe the steps of liver palpation?
When do hooking technique in liver palpation
applied?
Describe the normal edge of the liver?

7/1/2023 127
Spleen palpation
• Seldom palpable in
normal adults. Causes
include COPD, and
deep inspiratory
descent of the
diaphragm.

7/1/2023 128
Spleen palpation
• Support lower left rib
cage with left hand while
patient is supine and lift
anteriorly on the rib
cage.
• Palpate upwards toward
spleen with finger tips of
right hand starting the
RLQ
• Have the patient take a
deep breath and
synchronize palpation
with the breathing cycle

7/1/2023 129
Examination of Spleen (Palpation)
• Try to feel the tip or
edge of the spleen as it
comes down to meet
your fingertips.
• Note any tenderness,
assess the splenic
contour.
 Deep technique used
 Starting point is RLQ,
proceeding to LUQ

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7/1/2023 131
Repeat with the patient
lying on the right side
with legs somewhat
flexed at hips and knees.
In this position, gravity
may bring the spleen
forward and to the right
into a palpable location.

7/1/2023 134
Spleen palpation (Qs &As)
Describe the techniques of spleen palpation?
Where do you start spleen palpation?
To which direction do the spleen enlarge?

7/1/2023 136
Kidney palpation
• Move to the patient’s right
side.
• Place left hand posteriorly
just below the right 12th rib.
• Lift upwards; trying to
displace the kidney
anteriorly.
• Place your right hand gently
in the right upper quadrant,
lateral and parallel to the
rectus muscle.
Palpation of the Right Kidney.

7/1/2023 137
Examination of Kidney
• Ask patient to take a deep
breath.
• At the peak of inspiration,
press your right hand firmly
and deeply into the right
upper quadrant, just below
the costal margin
• Feel lower pole of kidney
and try to capture it between
your hands.
• If the kidney is palpable,
describe its size, contour,
and any tenderness.
NB: palpation of the left kidney is similar
to palpation of the right kidney except the
position of the examiner and the use of L
and R hand.

7/1/2023 138
Examination of Kidney
Right kidney may be felt to slip
between hands during exhalation
A normal right
kidney may be
palpable, especially
in thin and well-
relaxed women. It
may or may not be
slightly tender
The patient is
usually aware of a
capture and release.

7/1/2023 139
Examination of Aorta(Palpation)
• Flat palm placed over
the epigastrium to
locate pulse
• Press down deeply in
the midline above the
umbilicus.
• The aortic pulsation is
easily felt on most
individuals.

7/1/2023 140
Examination of Aorta(Palpation)
• Hands then oriented
vertically on either
side of midline with
distal fingers at
level of pulsation;
equal pressure
applied until
pulsation is
palpated
Lateral width of pulsation is determined by
space between index fingers

7/1/2023 141
Special exam
Abdominal examination

7/1/2023 142
Special exam
• Murphy’s Sign
• McBurney’s
Point
• Rovsing’s Sign
• Psoas Sign
• Obturator Sign
• Re bound
Tenderness
• Costovertebral
tenderness
• Shifting Dullness
• Fluid wave

7/1/2023 143
Murphy’s Sign
• A test for gallbladder
disease or sign of
gallbladder disease
consisting of pain on
taking a deep breath
when the examiner's
fingers are on the
approximate location of
the gallbladder.

7/1/2023 144
Murphy’s Sign
• Hook your left thumb or the fingers of your
right hand under the costal margin.
• Ask the patient to take a deep breath
• A sharp increase in tenderness with a sudden
stop in inspiratory effort constitutes a positive
Murphy’s sign of acute cholecystitis.
Look for Murphy’s sign when right upper
quadrant pain and tenderness suggest acute
cholecystitis,.
Techniques

7/1/2023 145
 McBurney’s Point
 Rovsing’s Sign
 Psoas Sign
 Obturator Sign
 Tenderness
 Rebound Tenderness
 Referred rebound tenderness
Are special exam/tests which are helpful in assessing possible
appendicitis
ASSESSING POSSIBLE APPENDICITIS
McBurney’s Point

7/1/2023 146
Position of patient in appendicitis Inflamed appendicitis

7/1/2023 147
McBurney’s Point
A site of extreme
sensitivity in acute
appendicitis, situated in the
normal area of the
appendix in the RLQ
Localized tenderness just
below midpoint of line
between right anterior
iliac crest and umbilicus.
Heel strike, riding over
bumps in road while
driving, coughing, will
produce pain.

7/1/2023 148
McBurney’s Point (Common Causes)
• Appendicitis
• Incarcerated or
strangulated hernia
• Ovarian torsion (twisted
Fallopian tube)
• Pelvic inflammatory
disease
• Abdominal abscess
• Hepatitis
• Diverticular disease
• Meckel''s diverticulum

7/1/2023 149
Rovsing’s Sign
• Sign of appendicitis
• Patient will experience
right lower quadrant
(RLQ) pain (in region
of McBurney’s Point)
when left lower
quadrant(LLQ) is
palpated.
 Referred rebound
tenderness: right lower
quadrant pain on quick
withdrawal of the LLQ

7/1/2023 150
Non-Classical Appendicitis
• Iliopsoas Sign
• Obturator Sign

7/1/2023 151
Iliopsoas Sign
This is pain felt when a weight is applied on the right
knee
Patient can lay on side and extend leg at the hip or have
patient lay on back and try to flex hip against the
resistance of examiner’s hand on thigh. If patient has an
inflamed retrocecal appendix, this will produce pain.

7/1/2023 152
Iliopsoas Sign
• Anatomic basis for the
psoas sign: inflamed
appendix is in a
retroperitoneal
location in contact with
the psoas muscle, which
is stretched by this
maneuver.

7/1/2023 153
Obturator Sign
• Internally rotate right leg at the hip with the knee at
90 degrees of flexion. Will produce pain if inflamed
appendix is in pelvis.

7/1/2023 154
Obturator Sign
• Anatomic basis for the
obturator sign: inflamed
appendix in the pelvis is
in contact with the
obturator internus
muscle, which is
stretched by this
maneuver.
Suggests appendicitis

7/1/2023 155
Tenderness
• What is the difference between tenderness
and pain?
–Tenderness is discomfort caused or
increased by their examination (a sign)
–Pain on the other hand, is something the
person tells you about as part of the history
(a symptom, may also have observable
manifestation)

7/1/2023 156
Rebound Tenderness
(For peritoneal irritation)
Warn the patient what you
are about to do.
• Press deeply on the
abdomen with your hand.
• After a moment, quickly
release pressure.
• If it hurts more when you
release, the patient has
rebound tenderness.

Rebound tenderness
7/1/2023 157
Do this when
symptoms present
Place fingers
perpendicular to skin
Push in slowly
Let out quickly
Pain on release of
pressure is positive for
peritoneal irritation

Fist Percussion of Kidneys
7/1/2023 158
Done in R & L Costo-
vertebral angles to assess
kidney tenderness
Warn the person what you
are about to do
Have the person sit up on
the exam table
Use the heel of your closed
fist to strike the person
firmly over the costo-
vertebral angles
Many times pressure from
fingertips is painful and
then you do not need to
percuss

7/1/2023 159
Cost vertebral Tenderness
(Often with renal disease)
• Use the heel of your
closed fist to strike the
patient firmly over the
costovertebral angles
(the angle formed by the
lower border of the 12th
rib and the transverse
processes of the upper
lumbar vertebrae).
• Compare the left and
right sides.

7/1/2023 161
Kidney palpation
Describe fist percussion?
Where is the location of the Costovertebral
angle?
What are the possible causes of pain in kidney
fist percussion/CVA tenderness?

Assessing Possible Ascitis
• A protuberant abdomen with bulging flanks
suggests the possibility of ascitic fluid.
• Because ascitic fluid characteristically sinks with
gravity, while gas-filled loops of bowel float to
the top, percussion gives a dull note in
dependent areas of the abdomen.
• If you note a protruding abdomen with bulging
flanks and dull percussion sounds in dependent
areas, you might perform two tests for assessing
ascites.
1. Test for shifting dullness.
2. Test for fluid wave
7/1/2023 162

7/1/2023 163
Shifting Dullness
(For peritoneal fluid)
• Assess for areas of tympani
and dullness by percussion
while your patient is supine.
• Percuss from anterior
abdomen laterally to outline
areas of dullness noted
• Lie him on one side
• Percuss again, noting once
more any areas of tympani
and dullness

7/1/2023 164
Examination for Shifting Dullness
• Patient rolled slightly
toward the examined
side; movement of the
dull point medially is
described as “shifting
dullness” and suggests
ascites

7/1/2023 165
Shifting Dullness
If the patient has ascites, the area of
dullness will shift down to the dependent
side and the area of tympani will shift up.

7/1/2023 166
The extra hand/patient’s as a pressure helps to
stop the transmission of a wave through fat.

7/1/2023 167
Fluid wave
An easily palpable impulse suggests ascites.

7/1/2023 168
Assessing Ventral Hernias
• Ventral hernias are hernias in the abdominal
wall exclusive of groin hernias.
• If you suspect but do not see an umbilical or
incisional hernia, ask the patient to raise both
head and shoulders off the table.
• The bulge of a hernia will usually appear with
this action.

7/1/2023 169
Recording the physical examination-
Abdomen
• “Abdomen is protuberant with active bowel sounds. It
is soft and nontender;no 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.”
OR
• “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 CVA tenderness.

7/1/2023 170
Assessing Ascitis(Q&A)
How do you assess ascitis?
Describe the steps to test for fluid shift?
Describe the steps to test for fluid wave?

7/1/2023 171
Relevant History
Changes in bowel habits
Diarrhea
Constipation
Alternating diarrhea and constipation
Frank blood in stools
Tarry stools
Changes in Appetite
Anorexia
Polyphagia

• Characteristics of
vomitus
Partially digested food
Undigested food
Fecal material
Frank blood
“Coffee grounds”
• Timing of emesis
Meals, Activities
Abdominal Pain
Timing
Course
Location
Quality
Radiation
 Characteristics
Steady/constant
Often well localized
Not related to peristalsis
Person lies still with knees
up
7/1/2023 172
Relevant History
Emesis: Vomiting

A. Liver edge
B. Spleen
edge
C. Rovsing’s
sign
D. Psoas sign
E. Obturator
sign
1. Palpable deep to the left costal margin during
inspiration
2. Palpable below the right costal margin in the
midclavicular line during inspiration
3. Pain elicited when the patient’s right thigh is
flexed at the hip with the knee bent, and the leg
is internally rotated at the hip
4. Examiner’s hand is placed on the patient’s right
knee and the patient is asked to raise his or her
right thigh against the examiner’s hand
5. Pain elicited by gently picking up a fold of
abdominal skin anteriorly
6. Pain in the right lower quadrant during palpation
of the left lower quadrant
7/1/2023 173
Active Listening Exercise
Matching

1. A 40-year-old merchant presents to your office
for evaluation of abdominal pain. It is worse after
eating, especially if she has a meal that is spicy or
high in fat. She has tried over-the-counter
antacids, but they have not helped the pain. After
examining her abdomen, you strongly suspect
cholecystitis. Which sign on examination
increases your suspicion for this diagnosis?
A. Psoas sign
B. Rovsing’s sign
C. Murphy’s sign
D. Grey Turner’s sign
7/1/2023 174
Quizzes

BEST WISHES TO ALL OF YOU!!!!!!
176
I THANK YOU ALL!!!!!!
7/1/2023

11. Final Abdominal Examination.ppt

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11. Final Abdominal Examination.ppt