1. Abdominal Physical Examination
Joel Niznick MD FRCPC

2. Acknowledgements Adapted from Public Domain Web Slide-sets by:
Jim Pierce, MD
Luke Palmisano, MS III
Kamilee Christenson, MS II
H.A.Soleimani MD

3. The History and Physical in Perspective
70% of diagnoses can be made based on history alone.
90% of diagnoses can be made based on history and physical exam.
Expensive tests often confirm what is found during the history and physical.
Assess the acuity of the patient to focus your differential diagnosis

4. General principles of exam
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

5. General principles of exam
If muscles remain tense, patient may be asked to rest feet on table with hips and knees flexed

6. Other helpful points on examination
Take a spare bed sheet and drape it over their lower body such that it just covers the upper edge of their underwear

7. General principles of exam
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. 1

8. Think Anatomically & Systemically
Inspection
Auscultation
Palpation
Percussion
Special maneuvers

9. General Observations
BMI, waist circumference, cachexia clubbing, jaundice, asterixis
Eyes: Sclera (colour), conjunctiva (pallor)
Head and neck: Spider nevi, dentition, fetor hepaticus, JVP, supraclavicular nodes
Chest: gynecomastia, spider nevi
Pheriphery: edema

10. Abdominal Inspection Scars Scaphoid/Distension Masses Peristalsis
Movement with respiration
Venous distension
Echymoses

11. Stigmata Chronic Liver Disease
Clubbing
Leukonychia
Palmar erythema
Dupuytren’s contracture
Spider nevi
Gynecomastia

12. Liver Stigmata Testicular atrophy Loss of axillary hair
Parotid enlargement
Ascites
Caput medusa
Peripheral edema

13. Liver Stigmata

14. Signs of Hemorrhagic Pancreatitis
Grey-Turner’s Sign
Cullen’s Sign

15. The Real Inspection

16. Scars and Wounds

17. Pfannenstiel Incision

20. Abdominal Anatomy Key Point: The Abdomen is 3D
It has a top – the diaphragm
It has a front and sides – the abdominal wall
It has a back – the back and retroperitoneum
It has a bottom – the pelvis

21. The TOP of the Abdomen

22. Anterior Abdominal Exam

23. Abdominal Surface Anatomy

24. Abdominal Deep Anatomy
Stomach
Pancreas
Pseudocyst
Colon
AAA
Liver
Spleen
Stomach
Colon
Kidney
Gall bladder
Colon
Kidney
Appendix
IBD mass
Colon Ca
Ovary
Kidney Tx
IBD Mass
Colon Ca
Stool mass
Ovary
Bladder
Uterus

25. Anterior Abdomen: Auscultation
Auscultate before palpation so as not to stimulate bowel sounds
Auscultate for
Bowel Sounds: Hyperdynamic, Normal, Occasional,Absent
Bruits / Hums
Rubs

26. Bowel Sounds

27. Abdominal Vasculature

28. Bruit
Bruits confined to systole do not necessarily indicate disease.

29. Auscultation for vascular 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)

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

31. Rubs

32. Rubs –Rubs-Rubs Liver Spleen Cardiac Pulmonary
Right and left upper quandrants
Grating sound with respiratory movement
Indicates inflammation of the capsule of the liver or spleen (infection or infarction).

33. Venous Hum (rare) Epigastric/umbilical area.
Soft humming noises in systolic/diastolic component.
Indicates collateral between portal and venous systems as in hepatic cirrhosis.

34. Percussion versus Palpation
Light Palpation assesses:
Masses and Tenderness in the Wall
Deep Palpation assesses:
Masses and Tenderness in the Cavity
Percussion assesses:
Location of organs
Location of masses
Deep tenderness

35. Tenderness

36. Light Palpation Inquire as to location of tenderness
Start with light palpation away from tenderness
Assess rigidity and guarding (voluntary/involuntary)
Assess for rebound tenderness
Palpate all 9 regions

37. Deep Palpation

38. Deep Palpation (alternatives)

39. Deep Palpation Start in non-tender area-move towards tenderness
Generally start in LLQ
Palpate for masses and deep tenderness
Palpate for organs
Liver, spleen, kidneys
Palpate for AAA

40. Anterior Abdominal Exam: Percussion
Nontender Abdomen
Location of Liver, Spleen
Succussion Splash of Stomach
Gas in Small / Large Intestine
Fluid in the Peritoneum
Tender Abdomen
Location and Severity of Tenderness
Presence of signs of peritonitis
Guarding, rigidity, rebound tenderness

41. Liver Palpation Start in RLQ/MCL Move hand up as patient inspires
Gradually move position up towards costal margin with each inspriation
Feel for liver edge as patient inspires
Normal liver edge smooth and soft
Describe liver edge if abnormal
Hard/firm/nodular
Normal liver cm in MCL
Percuss top of liver in held inspiration
Scratch test

42. Liver palpation Hand held steady Patient inhales Patient breathes
Hand lifted and moved up

43. Alternate Method Liver palpation
Stand by the patient's chest.
"Hook" your fingers just below the costal margin and press firmly.

44. Hepatomegaly More than 1cm below the costal margin
An exception is a congenitally large right lobe of the liver
Severe, chronic emphysema pushes liver down

45. Pulsation transmitted from aorta or due to severe tricuspid valve insufficiency

46. Hepatojugular reflux sign
If you press the liver, you will find the dilated jugular vein becomes more bulged or distended, as from the enlargement of liver passive congestion resulted from right failure.

47. Ballotable sign

48. Splenic palpation Start in RLQ Move hand up with inspiration
Reposition on expiration
Migrate palpation towards left costal margin
Feel for notched splenic surface
If spleen not felt roll patient in right decubitus position
Support lrfy podterior costal margin with left hand and palpate under costal margin with right hand
Percuss Traube’s space for dullness

49. Splenic palpation Seldom palpable in normal adults.
Causes include COPD, and deep inspiratory descent of the diaphragm.

50. Splenic palpation
Support lower left rib cage with left hand while patient is supine and lift anteriorly on the rib cage.

51. Splenic palpation
Palpate upwards toward spleen with finger tips of right hand, starting below left costal margin.
Have the patient take a deep breath.

52. Splenic palpation Deep technique used
Starting point is RLQ, proceeding to LUQ

54. Kidney palpation
Place left hand posteriorly just below the right 12th rib. Lift upwards.
Palpate deeply with right hand on anterior abdominal wall.

55. Kidney palpation Patient take a deep breath.
Feel lower pole of kidney and try to capture it between your hands.

56. Right kidney may be felt to slip between hands during exhalation

57. Examination of Aorta
Flat palm placed over the the epigastrium to locate pulse

58. Examination of Aorta
Press down deeply in the midline above the umbilicus.
The aortic pulsation is easily felt on most individuals.

59. Examination of Aorta
Hands then oriented vertically on either side of midline with distal fingers at level of pulsation; equal pressure applied until pulsation is palpated
A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.

60. Examination of Aorta
Lateral width of pulsation is determined by space between index fingers or finger and thumb

61. Abdominal Aortic Aneurysm
Palpable pulsatile mass
Patient feeling of pulsation
On rare occasions, a lump can be visible.
May rupture leading to shock and death
If ruptures into IVC = continuous murmur

62. Abdominal examination Special maneuvers

63. Special exam Rebound Tenderness Murphy’s Sign McBurney’s Point
Rovsing’s Sign
Psoas Sign
Obturator Sign
Costovertebral tenderness
Spinal percussion tenderness
Shifting Dullness
Fluid wave

64. Murphy’s Sign (acute cholecystitis)
Examiner’s hand is at middle inferior border of liver.
Patient is asked to take deep inspiration.
If positive patient will experience pain and will stop short of full inspiration
Hepatitis, subdiaphragmatic abscess Cholecystitis

65. McBurney’s Point
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.

66. 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

67. Rovsing’s Sign
Patient will experience right lower quadrant pain (in region of McBurney’s Point) when left lower quadrant is palpated.

68. Non-Classical Appendicitis
Iliopsoas Sign
Obturator Sign

69. Iliopsoas Sign
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.

70. 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.

71. 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.

72. 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.

73. 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.

74. Cost vertebral Tenderness (Often with renal disease)
Use the heel of your closed fist to strike the patient firmly over the costovertebral angles.
Compare the left and right sides.

75. Posterior Abdominal Exam: Percussion

76. 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

77. Ascites / Liver Disease

78. Shifting Dullness

79. Fluid Wave

81. Additional Examinations
Inguinal hernia
Femoral hernia

82. Additional examinations
Pelvic exam
Rectal exam

83. Questions?