PCM1: Abdominal Exam

=Physical Exam: Abdomen=

Demonstrate Draping

 * 1) Ask the patient to lie on a level examination table that is at a comfortable height for both of you. At this point, the patient should be dressed in a gown and, if they wish, underwear.
 * 2) Take a spare bed sheet and drape it over their lower body such that it just covers the upper edge of their underwear (or so that it crosses the top of the pubic region if they are completely undressed). This will allow you to fully expose the abdomen while at the same time permitting the patient to remain somewhat covered. The gown can then be withdrawn so that the area extending from just below the breasts to the pelvic brim is entirely uncovered, remembering that the superior margin of the abdomen extends beneath the rib cage.
 * 1) The patient's hands should remain at their sides with their heads resting on a pillow. If the head is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend their knees so that the soles of their feet rest on the table will also relax the abdomen.

Describe the topographical areas of the abdomen

 * 4 divisions: left upper quadrant, left lower quadrant, right upper quadrant, right lower quadrant
 * 9 divisions:

Identify Femoral and inguinal lymph node regions (see pictures)

Inspection

 * Contour: –Flat, Scaphoid, Protuberant, Distended, Obese
 * Scars
 * Veins
 * Pulsations
 * Hernias

pay particular attention to:
 * 1) Appearance of the abdomen. Is it flat? Distended? If enlarged, does this appear symmetric or are there distinct protrusions, perhaps linked to underlying organomegaly? The contours of the abdomen can be best appreciated by standing at the foot of the table and looking up towards the patient's head. Global abdominal enlargement is usually caused by air, fluid, or fat. (Five Fs of a distended abdomen: fluid, flatus, fat, feces, fetus.) It is frequently impossible to distinguish between these entities on the basis of observation alone (see below for helpful maneuvers). Areas which become more pronounced when the patient valsalvas are often associated with ventral hernias. These are points of weakening in the abdominal wall, frequently due to previous surgery, through which omentum/intestines/peritoneal fluid can pass when intra-abdominal pressure is increased
 * 2) Presence of surgical scars or other skin abnormalities.
 * 3) Patient's movement (or lack thereof). Those with peritonitis (e.g. appendicitis) prefer to lie very still as any motion causes further peritoneal irritation and pain. Contrary to this, patients with kidney stones will frequently writhe on the examination table, unable to find a comfortable position.

Auscultation
Compared to the cardiac and pulmonary exams, auscultation of the abdomen has a relatively minor role. It is performed before percussion or palpation as vigorously touching the abdomen may disturb the intestines, perhaps artificially altering their activity and thus bowel sounds. Exam is made by gently placing the pre-warmed (accomplished by rubbing the stethoscope against the front of your shirt) diaphragm on the abdomen and listening for 15 or 20 seconds. There is no magic time frame, but for a very sick patient, the clinical criteria is five minutes without a bowel sounds is necessary to say the bowel is inactive. The stethoscope can be placed over any area of the abdomen as there is no true compartmentalization and sounds produced in one area can probably be heard throughout. Three things should be noted:
 * 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)?

Percussion
The technique for percussion is the same as that used for the lung exam. First, remember to rub your hands together and warm them up before placing them on the patient. Then, place your left hand firmly against the abdominal wall such that only your middle finger is resting on the skin. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your right middle finger, using the previously described floppy wrist action (see under lung exam). There are two basic sounds which can be elicited: The two solid organs which are percussable in the normal patient are the liver and spleen. In most cases, the liver will be entirely covered by the ribs. Occasionally, an edge may protrude a centimeter or two below the costal margin. The spleen is smaller and is entirely protected by the ribs.
 * 1) Tympanitic (drum-like) sounds produced by percussing over air filled structures.
 * 2) Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies beneath the region being examined.
 * Special note should be made if percussion produces pain, which may occur if there is underlying inflammation, as in peritonitis.
 * Percuss for the liver: a normal liver span is 6-12 cm.

Palpation

 * 1) Gently palpate all 4 quadrants
 * 2) Deeply palpate all 4 quadrants, liver, spleen
 * 3) Test for rebound tenderness

First warm your hands by rubbing them together before placing them on the patient. The pads and tips (the most sensitive areas) of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures. You may use either your right hand alone or both hands, with the left resting on top of the right. Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely to startle the patient or cause discomfort. Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel. Gently push down (posterior) and towards the patient's head with your hand oriented roughly parallel to the rectus muscle, allowing the greatest number of fingers to be involved in the exam as you try to feel the edge of the liver. Advance your hands a few cm cephelad and repeat until ultimately you are at the bottom margin of the ribs. Initial palpation is done lightly. Following this, repeat the examination of the same region but push a bit more firmly so that you are interrogating the deeper aspects of the right upper quadrant, particularly if the patient has a lot of subcutaneous fat. Pushing up and in while the patient takes a deep breath may make it easier to feel the liver edge as the downward movement of the diaphragm will bring the liver towards your hand. The tip of the xyphoid process, the bony structure at the bottom end of the sternum, may be directed outward or inward and can be mistaken for an abdominal mass. You should be able to distinguish it by noting its location relative to the rib cage (i.e. in the mid-line where the right and left sides meet).

Summary for Abdomen

 * 1) Inspect skin for contour, markings, venous markings & changes w/ respiration
 * 2) Auscultate all 4 quadrants for bowel sounds
 * 3) Lightly, then deeply palpate all 4 quadrants: 1) LUQ, 2) LLQ, 3) RLQ, 4) RUQ
 * 4) Percuss all 4 quadrants for tone
 * 5) Percuss liver borders and estimate span
 * 6) Percuss left midaxillary line for splenic dullness
 * 7) Palpate left costal margin for spleen: Place hand on Left Upper abdomen. #Instruct pt to inhale as you begin palpating. Have them exhale as you deepen the palpation.
 * 8) Palpate right costal margin for liver border: Place hand on Right Upper abdomen. Instruct pt to inhale as you begin palpating. Have them exhale as you deepen the palpation.
 * 9) Palpate for right and left kidneys (optional? Not on main PE list)

Pain

 * Pain in foregut structures:   referred areas
 * Pain in midgut structures:   referred areas
 * Pain in hindgut structures:  referred areas
 * a lot of detail in chart Mosby p.552

=PCM2 Objectives: Refine Abdominal Exam=

List at least five relevant questions to ask when assessing an individual with each of the following complaints

 * Hematemesis: OPSRST, color, quantity, travel, history of gastritis, NSAIDs, trauma.
 * Acute abdominal pain: OPQRST, fever, loss of appetite, nausea/vomiting, trauma, bowel habits.
 * Change in bowel habits: color, consistency, frequency, feverl, dietary changes, recent travel, hematochezia, triggers.

List three examination findings anticipated with the following problems

 * acute abdomen: Guarding, rebound tenderness, absent peristaltic bowel sounds, fever.
 * cirrhosis: abnormal liver size, jaundice or scleral icterus, caput medusa/varicies, increased estrogen (gynecomastia, testicular atrophy, spider angiomata)
 * ascites: Fluid wave, shifting dullness, distended abdomen.
 * pancreatitis: Epigastric pain radiating to the back, emesis, hyperglycemia or new onset diabetes mellitus, Grey Turner’s sign and hypotension (if pancreas ruptured causing severe bleeding).
 * cholecystitis: Positive Murphy’s sign (RUQ pain on deep palpation), fever, radiating pain to right subscapular area
 * inflammatory bowel disease: Hematochezia, abdominal pain (any region), fistulae (Crohn’s disease), weight loss, vomiting, diarrhea.
 * pancreatic cancer: weight loss, painless jaundice, epigastric pain radiating to the back, diabetes mellitus or hyperglycemia.
 * appendicitis: Positive psoas sign (flex leg while lying supine), positive obturator sign (internal rotation of the hip with knee flexed), positive Rosving’s sign (pain in RLQ upon palpation of LLQ).
 * enlarged liver (greater than the normal 6-12 cm span)

=Links=
 * http://meded.ucsd.edu/clinicalmed/abdomen.htm