- The abdomen should be examined with the patient supine1
- Rectal examination should be considered depending on presentation
- Genitourinary examination should be considered depending on presentation
Abdomen
GENERAL EXAM
GENERAL
INSPECTION
- General
- How does the patient look?
- Do they look sick?
- Skin
- Color: erythema, ecchymosis, white, black
- Trophic changes (altered hair growth, sweat production)
- Scars
- Cyanosis
- Swelling
- Muscle tone: atrophy, hypertrophy
- Deformity: asymmetry, rotation, amputation
- Areas of interest
- Presence of surgical scars
- Obesity of abdomen
- Distension
- Masses or bulges
- Grey Turner sign: ecchymosis of the flank and groin
- Cullen’s sign: periumbilical ecchymosis
- Pink or purple striae
- Caput Medusa: distended veins flowing away from the umbilicus
- Ascites
- Swollen lymph nodes
- Also look for
- Pallor (conjunctival, mucosal)
- Jaundice or scleral icterus
- Petechiae
AUSCULTATION
- Normal: low pitched, gurgling
- Normally heard every 5-10 seconds
- Hyperactive
- Hypoactive
- Absent
- Bruit2
PALPATION
- General
- Patient should be relaxed
- Start with light palpation before deep palpation
- Pressure should be slow, steady
- Save self reported area of pain for last
- May require “distraction” by examiner
- Palpate by region/ area
- Right upper quadrant
- Right flank
- Right lower quadrant
- Epigastric
- Periumbilical
- Suprapubic
- Left upper quadrant
- Left flank
- Left lower quadrant
- Potential Findings
- Focal tenderness
- Nonfocal or diffuse tenderness
- Organomegaly (spleen, liver)
- Masses
- Rebound tenderness
- Guarding (voluntary or involuntary)
- Crepitus
- Pulsatile mass
- Hernia
- Additional pearls
- Asking the patient to cough can increase intra-abdominal pressure and increase protrusion of mass
PERCUSSION
- General
- Can be performed “separately” or as part of palpation exam
- Tympany: heard over air-filled viscera
- Dull: heard over solid organs
- Define borders of liver, spleen
- Note will change from tympanitic to dull
- Costovertebral angle
- Check for ascites
RECTAL
- Externally inspect for
- External blood
- Fissure
- Fistula
- External hemorrhoids
- Palpation (digital rectal exam)
- Use a lubricated gloved finger
- Slide slowly to, gently to dilate the sphincter
- Palpate for hemorrhoids, foreign body
- Presence or absence of stool in rectal vault
- Prostate can be examined if clinically appropriate
- After exam
- Examine finger for any signs of blood or melena in stool
- Consider guaiac test as clinically appropriate
SPECIAL TESTS / VIDEOS
- Appendicitis
- McBurney’s point: tenderness ⅓ of the distance from ASIS to umbilicus
- Rovsing’s sign: deep palpation of the left lower quadrant causing pain on the right lower quadrant
- Psoas sign; activation of right psoas muscle with hip flexion recreating pain
- Obturator sign: Flexing, internally rotating hip and knee causing increased pain
OTHER
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CITATIONS
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