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- 2. REFERENCE:
- 3. Tips for Abdominal Examination ● Make the patient comfortable in the supine position, with a pillow under the head and perhaps under the knees. ● Ask the patient to keep the arms at the sides or folded across the chest. ● Draping the patient ● Before you begin, ask the patient to point to any areas of pain so that you can examine these areas last. ● Warm your hands and stethoscope. ● Approach the patient calmly and avoid quick unexpected movements. ● Stand at the patient’s right side and proceed in a systematic fashion with inspection, auscultation, percussion, and palpation. ● If necessary, distract the patient with conversation or questions.
- 4. Inspection ● General Appearance ○ Temperature ○ Color ○ Scars ○ Striae ○ Dilated veins ○ Rashes or ecchymoses
- 5. Inspection ● The umbilicus ○ Contour, location, inflammation ● Contour of the Abdomen ○ Flat, Rounded, Protuberant or Scaphoid ○ Flanks bulges ○ Symmetric ○ Visible organs or masses ● Peristalsis ○ Thin people ● Pulsations ○ Aortic Pulsation
- 6. Auscultation ● Bowel sounds ○ Frequency- clicks and gurgles 5-34 per minute ○ Character- borborygmi RLQ ● Bowel sounds may be: ● ■ Increased, as in diarrhea or early intestinal obstruction ● ■ Decreased, then absent, as in adynamic ileus and peritonitis. ● Before deciding that bowel sounds are absent, sit down and listen where shown for 2 min or even longer. ● High-pitched tinkling sounds suggest intestinal fluid and air under tension in a dilated bowel. Rushes of high-pitched sounds coinciding with an abdominal cramp signal intestinal obstruction.
- 7. Auscultation ● Bruits ○ A hepatic bruit suggests carcinoma of the liver or cirrhosis. ○ Arterial bruits with both systolic and diastolic components suggest partial occlusion of the aorta or large arteries. ○ Bruits in the epigastrium are suspicious for renal artery stenosis or renovascular hypertension.
- 8. Auscultation ● Friction Rub ○ Friction rubs are rare grating sounds with respiratory variation. ○ They indicate inflammation of the peritoneal surface of an organ, as in liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct. ○ When a systolic bruit accompanies a hepatic friction rub, suspect carcinoma of the liver.
- 9. Auscultation ● Venous Hum ○ A venous hum is a rare soft humming noise with both systolic and diastolic components. ○ It points to increased collateral circulation between portal and systemic venous systems, as in hepatic cirrhosis.
- 10. Percussion ● Note any dull areas suggesting an underlying mass or enlarged organ. This observation will guide subsequent palpation. ● On each side of a protuberant abdomen, note where abdominal tympany changes to the dullness of solid posterior structures. ● Briefly percuss the lower anterior chest above the costal margins. On the right, you will usually find the dullness of the liver; on the left, the tympany that overlies the gastric air bubble and the splenic flexure of the colon.
- 11. Palpation ● Light Palpation ○ Gentle palpation aids detection of abdominal tenderness, muscular resistance, and some superficial organs and masses. It also reassures and relaxes the patient. ○ Identify any superficial organs or masses and any area of tenderness or increased resistance to palpation ■ Palpate after asking the patient to exhale, which usually relaxes the abdominal muscles. ■ Ask the patient to mouth-breathe with the jaws wide open.
- 12. Palpation ● Deep Palpation ○ Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses
- 13. Palpation ● Signs of Peritonitis ○ Guarding ○ Rigidity ○ Rebound Tenderness
- 15. Percussion 1. Identify the lower border of dullness in the MCL ➢ Start: level below umbilicus in the RLQ. ➢ Percuss upward towards the liver 1. Identify the upper border of liver dullness: ➢ Start: nipple line ➢ Percuss downward in the MCL until lung resonance shifts to liver dullness.
- 16. Percussion 3. Vertical span of liver dullness: measure the cm between the 2 points 4. If liver seems enlarged, outline LOWER EDGE : percuss medially & laterally
- 17. Palpation 1. Place your left hand behind the patient, parallel to and supporting the right 11th and 12th ribs and adjacent soft tissues below. 2. Press left hand upward 3. Place your right hand on the patient’s right abdomen lateral to the rectus muscle, with your fingertips well below the lower border of liver dullness 4. Ask the patient to take a deep breath. 5. Try to feel the liver edge as it slides down to meet your fingertips.
- 18. Palpation 6. liver edge: adapt your examining pressure to the thickness and resistance of the abdominal wall. - If you cannot feel the edge, move your palpating hand closer to the costal margin and try again. 6. Trace the liver edge both laterally and medially.
- 19. Hooking Technique 1. Stand to the right of the patient’s chest. 2. Place both hands, side by side, on the right abdomen below the border of liver dullness. 3. Press in with your fingers and up toward the costal margin 4. Ask the patient to take a deep breath. 5. The liver edge shown in Figure 11-19 is palpable with the fingerpads of both hands.
- 20. The Spleen bates' video: Spleen examination - YouTube
- 21. Percussion 1. Percuss the left lower anterior chest wall roughly from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin. - As you percuss along the routes marked by the arrows in the Figures 11-20 and 11-21, note the lateral extent of tympany
- 22. Percussion SPLENIC PERCUSSION SIGN 1. Percuss the lowest interspace in the left anterior axillary line 2. Then ask the patient to take a deep breath, and percuss again. 3. When spleen size is normal, the percussion note usually remains tympanitic. If it becomes dull, positive.
- 23. Palpation 1. With your left hand, reach over and around the patient to support and press forward the lower left rib cage and adjacent soft tissue. 2. Right hand below the left costal margin, press in toward the spleen. 3. Ask the patient to take a deep breath. 4. Try to feel the tip or edge of the spleen as it comes down to meet your fingertips 5. Note any tenderness, assess the splenic contour.
- 24. Palpation 6. Repeat with the patient lying on the right side with legs somewhat flexed at the hips and knees
- 25. The Kidneys bates' video: Kidney & Aorta examination - YouTube
- 26. Palpation of the Left Kidney 1. Move to the patient’s left side. 2. Place your right hand behind the patient, just below and parallel to the 12th rib, with your fingertips just reaching the CVA. 3. Lift, trying to displace the kidney anteriorly. 4. Place your left hand gently in the LUQ, lateral and parallel to the rectus muscle. 5. Ask the patient to take a deep breath. At the peak of inspiration, press your left hand firmly and deeply into the LUQ, just below the costal margin. Try to “capture” the kidney between your two hands.
- 27. Palpation of the Left Kidney 6. Ask the patient to breathe out and then to stop breathing briefly. Slowly release the pressure of your left hand, feeling at the same time for the kidney to slide back into its expiratory position. 6. Alternatively, try to palpate the left kidney using the deep palpation technique similar to palpation of the spleen. Standing at the patient’s right side, with your left hand, reach over and around the patient to lift up beneath the left kidney, and with your right hand, feel deep in the LUQ. 6. Ask the patient to take a deep breath, and feel for a mass. A normal left kidney is rarely palpable.
- 28. Palpation of the Right Kidney ● To capture the right kidney, return to the patient’s right side. Use your left hand to lift up from the back, and your right hand to feel deep in the RUQ.
- 29. Percussion Tenderness of the Kidneys ● Assess percussion tenderness over the CVAs. ● Pressure from your fingertips may be enough to elicit tenderness; if not, use fist percussion. ○ Place the ball of one hand in the CVA and strike it with the ulnar surface of your fist. ○ Use enough force to cause a perceptible but painless jar or thud.
- 30. The Bladder
- 31. Palpation of the Right Kidney ● Percuss for dullness and the height of the bladder above the symphysis pubis. ● On palpation, the dome of the distended bladder feels smooth and round.
- 32. The Aorta
- 33. The Aorta ● Press firmly deep in the epigastrium, slightly to the left of the midline, and identify the aortic pulsations. ● In adults over age 50 years, assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta. ● Detection of pulsations is affected by abdominal girth and the diameter of the aorta.
- 35. Male Patient ● Inspect the sacrococcygeal and perianal areas for lumps, ulcers, inflammation, ashes, or excoriations ● Examine the anus and rectum ● Palpate the anal canal ● Palpate the rectal surface ● Palpate the prostate gland
- 36. Female Patient ● The rectum is usually examined after examining the female genitalia while the woman is in the lithotomy position. ● If only a rectal examination is needed, the lateral position is satisfactory and affords a better view to the perianal and sacrococcygeal areas.
- 38. Assessing Possible Ascites Percuss for dullness outward in several directions from the central area of tympany. Map the border between tympany and dullness
- 39. Assessing Possible Ascites Test for shifting dullness ● Percuss the border of tympany and dullness with the patient supine, then ask the patient to roll onto one side. ● Percuss and mark the borders again
- 40. Assessing Possible Ascites Test for a fluid wave ● Ask the patient or an assistant to press the edges of both hands firmly down the midline of the abdomen. ● While you tap one flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through the fluid.
- 41. Assessing Possible Ascites Identifying an Organ or Mass in an Ascitic Abdomen ● Try to ballotte the organ or mass ● Straighten and stiffen the fingers of one hand together, place them on the abdominal surface, and make a brief jabbing movement directly toward the anticipated structure.
- 42. Assessing Possible Appendicitis ● Ask the patient to point to where the pain began and where it is now. ● Ask the patient to cough to see where pain occurs. ● Palpate carefully for an area of local tenderness. ● Palpate the tender area for guarding, rigidity, and rebound tenderness. ● Palpate for Rovsing sign and referred rebound tenderness. ● Assess the psoas sign ● Obturator sign ● Perform a rectal examination and, in women, a pelvic examination.
- 43. Assessing Possible Acute Cholecystitis When RUQ pain and tenderness suggest acute cholecystitis, assess Murphy sign.
- 44. Assessing Ventral Hernias Ventral hernias are hernias in the abdominal wall exclusive of groin hernias.
- 45. Mass in the Abdominal Wall Occasionally, there are masses in the abdominal wall rather than inside the abdominal cavity. Ask the patient either to raise the head and shoulders or to strain down, thus tightening the abdominal muscles. Feel for the mass again.
- 46. Thank You!
Notas del editor
- ● Make the patient comfortable in the supine position, with a pillow under the head and perhaps under the knees. Slide your hand under the low back to see if the patient is relaxed and lying flat on the table. ● Ask the patient to keep the arms at the sides or folded across the chest. When the arms are above the head, the abdominal wall stretches and tightens, which hinders palpation. ● Draping the patient. To expose the abdomen, place the drape or sheet at the level of the symphysis pubis, then raise the gown to below the nipple line just above the xiphoid process. The groin should be visible but the genitalia should remain covered. The abdominal muscles should be relaxed to enhance all aspects of the examination, especially palpation. ● Before you begin, ask the patient to point to any areas of pain so that you can examine these areas last. ● Warm your hands and stethoscope. To warm your hands, rub them together or place them under hot water. ● Approach the patient calmly and avoid quick unexpected movements. Avoid having long fingernails which can scratch or scrape the patient’s skin. ● Stand at the patient’s right side and proceed in a systematic fashion with inspection, auscultation, percussion, and palpation. Visualize each organ in the region you are examining. Watch the patient’s face for any signs of pain or discomfort. ● If necessary, distract the patient with conversation or questions. If the patient is frightened or ticklish, begin palpation with the patient’s hand under yours. After a few moments, slip your hand underneath to palpate directly. Arching the back pushes the abdomen forward and tightens the abdominal muscles.
- From the right side of the bed, inspect the surface, contours, and movements of the abdomen. Watch for bulges or peristalsis. Try to sit or bend down so that you can view the abdomen tangentially Temperature. Check if the skin is warm, or cool and clammy. Color. Note any bruises, erythema, or jaundice. Scars. Describe or diagram their location. Striae. Old silver striae or stretch marks are normal. ( Pink–purple striae are a hallmark of Cushing syndrome.) Dilated veins. A few small veins may be visible normally. (Dilated veins suggest portal hyper- tension from cirrhosis (caput medusae) or inferior vena cava obstruction.) Rashes or ecchymoses (Ecchymosis of the abdominal wall is seen in intraperitoneal or retroperito- neal hemorrhage.)
- ■The umbilicus. Observe its contour and location and any inflammation or bulges suggesting a ventral hernia. The contour of the abdomen ■ Is it flat, rounded, protuberant, or scaphoid (markedly concave or hollowed)? ■ Do the flanks bulge, or are there any local bulges? Also survey the inguinal and femoral areas. (Observe for the bulging flanks of asci- tes, the suprapubic bulge of a distended bladder or pregnant uterus, and ven- tral, femoral, or inguinal hernias.) ■ Is the abdomen symmetric? (Asymmetry suggests a hernia, an enlarged organ, or a mass.) ■ Are there visible organs or masses? An enlarged liver or spleen may descend below the rib cage. (Inspect for the lower abdominal mass of an ovarian or a uterine cancer.) ■ Peristalsis. Observe the abdomen for several minutes if you suspect intestinal obstruction. Normally, peristalsis is visible in very thin people. (Inspect for the increased peristaltic waves of intestinal obstruction.) ■ Pulsations. The normal aortic pulsation is frequently visible in the epigastrium. (Inspect for the increased pulsations of an abdominal aortic aneurysm (AAA) or increased pulse pressure.)
- Auscultation provides important information about bowel motility. Auscultate the abdomen before performing percussion or palpation, maneuvers which may alter the characteristics of the bowel sounds. Learn to identify variations in normal bowel sounds, the changed sounds suggestive of peritoneal inflammation or obstruction, and bruits, which are vascular sounds resembling heart murmurs over the aorta or other arteries in the abdomen. Place the diaphragm of your stethoscope gently on the abdomen. 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. Occasionally you may hear the prolonged gurgles of hyperperistalsis from “stomach growling,” called borborygmi. Because bowel sounds are widely transmitted through the abdo- men, listening in one spot, such as the RLQ, is usually sufficient.
- Auscultate for bruits over the aorta, the iliac arteries, and the femoral arteries (Fig. 11-10).
- Auscultate over the liver and spleen for friction rubs.
- Percussion helps you assess the amount and distribution of gas in the abdomen, viscera and masses that are solid or fluid-filled, and the size of the liver and spleen. Percuss the abdomen lightly in all four quadrants to determine the distribution of tympany and dullness. Tympany usually predominates because of gas in the GI tract, but scattered areas of dullness from fluid and feces are also common. A protuberant abdomen that is tym- panitic throughout suggests intestinal obstruction or paralytic ileus. See Table 11-9, Protuberant Abdomens, p. 500. Dull areas characterize a pregnant uterus, an ovarian tumor, a distended bladder, or a large liver or spleen. Dullness in both flanks prompts further assessment for ascites (see pp. 484–485). In the rare condition of situs inversus, organs are reversed—air bubble on the right, liver dullness on the left.
- Keeping your hand and forearm on a horizontal plane, with fingers together and flat on the abdominal wall, palpate the abdomen with a light gentle dipping motion. As you move your hand to different quadrants, raise it just off the skin. Gliding smoothly, palpate in all four quadrants Identify any superficial organs or masses and any area of tenderness or increased resistance to palpation. If resistance is present, try to distinguish voluntary guarding from involuntary rigidity or muscular spasm. Voluntary guarding usually decreases with the techniques listed below. Involuntary rigidity typically persists despite these maneuvers, suggesting peritoneal inflammation.
- Again using the palmar surfaces of your fingers, press down in all four quadrants (Fig. 11-12). Identify any masses; note their location, size, shape, consistency, tenderness, pulsations, and any mobility with respiration or pressure from the examining hand. Correlate your findings from palpation with their percussion notes Assessing Possible Peritonitis. Inflammation of the parietal peritoneum, or peritonitis, signals an acute abdomen.Signs of peritonitis include a positive cough test, guarding, rigidity, rebound tenderness, and percussion tenderness. Even before palpation, ask the patient to cough and identify where the cough produces pain. Then palpate gently, starting with one finger then with your hand, to localize the area of pain. As you palpate, check for the peritoneal signs of guarding, rigidity, and rebound tenderness. (When positive, these signs roughly double the likelihood of peritonitis; rigidity makes peritonitis almost four times more likely.73 Causes include appendicitis, cholecystitis, and a perforation of the bowel wall.)
- ● Guarding is a voluntary contraction of the abdominal wall, often accompanied by a grimace that may diminish when the patient is distracted. ● Rigidity is an involuntary reflex contraction of the abdominal wall from peritoneal inflammation that persists over several examinations. ● Rebound tenderness refers to pain expressed by the patient after the examiner presses down on an area of tenderness and suddenly removes the hand. To assess rebound tenderness, ask the patient “Which hurts more, when I press or let go?” Press down with your fingers firmly and slowly, then withdraw your hand quickly. The maneuver is positive if withdrawal produces pain. Percuss gently to check for percussion tenderness.
- In liver, direct assessment is limited Liver size and shape can be estimated by: A. Percussion B. Palpation We usually evaluate the surface consistency and tenderness of the liver https://youtu.be/839KX_-B1O0
- When a spleen enlarges, it usually replaces the tympany of stomach and colon with the dullness of a solid organ. Dullness to percussion suggests splenic enlargement, but may be absent when enlarged spleens lie above the costal margin. Techniques of examination: Percussion Palpation https://youtu.be/dzrPuy_bszc
- https://youtu.be/IRC1r3oELGs
- 6b: If the kidney is palpable, describe its size, contour, and any tenderness. A left flank mass can represent either splenomegaly or an enlarged left kidney. Suspect splenomegaly if there is a palpable notch on medial border, the edge extends beyond the midline, percussion is dull, and your fingers can probe deep to the medial and lateral borders but not between the mass and the costal margin. Confirm these findings with further evaluation. Suspect an enlarged kidney if there is normal tympany in the LUQ and you can probe with your fingers between the mass and the costal margin, but not deep to its medial and lower borders. Causes of kidney enlargement include hydronephrosis, cysts, and tumors. Bilateral enlargement suggests polycystic kidney disease.
- 6b: If the kidney is palpable, describe its size, contour, and any tenderness. A left flank mass can represent either splenomegaly or an enlarged left kidney. Suspect splenomegaly if there is a palpable notch on medial border, the edge extends beyond the midline, percussion is dull, and your fingers can probe deep to the medial and lateral borders but not between the mass and the costal margin. Confirm these findings with further evaluation. Suspect an enlarged kidney if there is normal tympany in the LUQ and you can probe with your fingers between the mass and the costal margin, but not deep to its medial and lower borders. Causes of kidney enlargement include hydronephrosis, cysts, and tumors. Bilateral enlargement suggests polycystic kidney disease.
- A normal right kidney may be palpable, especially when the patient is thin and the abdominal muscles are relaxed. Proceed as before. The kidney may be slightly tender. The patient is usually aware of a capture and release. Occasionally, a right kidney is more anterior and must be distinguished from the liver. The lower pole of the kidney is rounded, and the liver edge, if palpable, tends to be sharper, and extends farther medially and laterally. The liver itself cannot be captured.
- To save the patient from repositioning, integrate this assessment into your examination of the posterior lungs or back. Pain with pressure or fist percussion supports pyelonephritis if associated with fever and dysuria, but may also be musculoskeletal.
- Normally, the bladder is not palpable unless it is distended above the symphysis pubis. To check for the presence or absence of distention, Percuss for dullness and the height of the bladder above the symphysis pubis. Bladder volume must be 400 to 600 mL before dullness appears. On palpation, the dome of the distended bladder feels smooth and round. Check for tenderness. Causes of bladder distention are outlet obstruction from a urethral stricture or prostatic hyperplasia, medication side effects, and neurologic disorders such as stroke or multiple sclerosis. Suprapubic tenderness is common in bladder infection.
- Press firmly deep in the epigastrium, slightly to the left of the midline, and identify the aortic pulsations. In adults over age 50 years, assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta. In this age group, a normal aorta is not more than 3 cm wide (average, 2.5 cm, excluding the thickness of the skin and abdominal wall). Detection of pulsations is affected by abdominal girth and the diameter of the aorta. Risk factors for AAA are age ≥65 years, history of smoking, male gender, and a first-degree relative with a history of AAA repair A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an AAA. Sensitivity of palpation increases as AAAs enlarge: for widths of 3 to 3.9 cm, 29%; 4 to 4.9 cm, 50%; ≥5 cm, 76%.
- Inspect the sacrococcygeal and perianal areas for lumps, ulcers, inflammation, ashes, or excoriations. Adult perianal skin is normally more pigmented and somewhat coarser than the skin over the buttocks. Palpate any abnormal areas, noting lumps or tenderness. Anal and perianal lesions include hemorrhoids, venereal warts, herpes, syphilitic chancre, and carcinoma. A linear crack or tear suggests anal fissure from large, hard stools, IBD, or STIs. Consider pruritus ani if there is swollen, thickened, fissured perianal skin with excoriations. Examine the anus and rectum. Lubricate your gloved index finger, explain to the patient what you are going to do, and tell him that the examination may trigger an urge to move his bowels but this will not occur. Ask him to bear down as if having a bowel movement. Inspect the anus, noting any lesions Palpate the anal canal. As the patient bears down, place the pad of your gloved and lubricated index finger over the anus (fig 15-6A) . As the sphincter relaxes, gently insert your fingertip into the anal canal in the direction pointing toward the umbilicus (15-6B). If you feel the sphincter tighten, pause and reassure the patient. When, in a moment, the sphincter relaxes, proceed. A tender purulent reddened mass with fever or chills suggests an anal abscess. Abscesses tunneling to the skin surface from the anus or rectum may form a clogged or draining anorectal fistula. Fistulas may ooze blood, pus, or feculent mucus. Consider anoscopy or sigmoidoscopy for better visualization. Occasionally, severe tenderness prevents entry and internal examination. Do not apply force. Instead, place your fifingers on both sides of the anus, gently spread the orififice, and ask the patient to bear down. If you can proceed without undue discomfort to the patient, note: The sphincter tone of the anus. Normally, the muscles of the anal sphincter close snugly around your fifinger. Initial resting tone reflflects the integrity of the internal anal sphincter. To check external sphincter tone, ask the patient to squeeze your fifinger with the rectal muscles. Sphincter tightness may occur with anxiety, inflammation, or scarring. Sphincter laxity occurs in neurologic diseases, such as S2–S4 cord lesions, and signals possible changes in the urinary sphincter and detrusor muscle. Consider testing perianal sensation. Tenderness, if any Look for a lesion, such as an anal fissure, that might explain tenderness Induration Induration may be caused by inflammation, scarring, or malignancy. Irregularities or nodules Palpate the rectal surface. Insert your finger into the rectum as far as possible. Rotate your hand clockwise to palpate as much of the rectal surface as possible on the patient’s right side, then counterclockwise to palpate the surface posteriorly and on the patient’s left side (15-7) Note any nodules, irregularities, or induration. To bring a possible lesion into reach, take your fifinger off the rectal surface, ask the patient to bear down, and palpate again. Note any masses with irregular borders suspicious for rectal cancer Palpate the prostate gland Then rotate your hand further counterclockwise so that your fifinger can examine the posterior surface of the prostate gland (15-9). By turning your body slightly away from the patient, you can feel this area more easily. Tell the patient that examining his prostate gland may prompt an urge to urinate Sweep your fifinger carefully over the prostate gland, identifying its lateral lobes and the groove of the median sulcus between them (15-10) Note the size, shape, mobility, and consistency of the prostate, and identify any nodules or tenderness. The normal prostate is rubbery and nontender, with no evidence of fixity to the surrounding tissues. If possible, extend your finger above the prostate to the region of the seminal vesicles and the peritoneal cavity and sweep the anterior wall. Note any nodules or tenderness. Findings include a rectal “shelf” of peritoneal metastases or the tenderness of peritoneal inflammation Gently withdraw your finger, and wipe the anus or give the patient tissues. Note the appearance of any fecal matter on your glove
- The rectum is usually examined after examining the female genitalia while the woman is in the lithotomy position. This position allows you to conduct the bimanual examination, delineate a possible adnexal or pelvic mass, test the integrity of the rectovaginal wall, and may help you to palpate a cancer high in the rectum. If only a rectal examination is needed, the lateral position is satisfactory and affords a better view to the perianal and sacrococcygeal areas. Use the same techniques for examination that you use for men. Note that the cervix is readily palpated through the anterior rectal wall. Sometimes, a retroverted uterus is also palpable. Do not mistake either of these, or a vaginal tampon, for a suspicious mass. Recording the Anus, Rectum, and Prostate Examination “No perirectal lesions or fifissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and nontender with palpable median sulcus. (Or in a female, uterine cervix nontender.) Stool brown; no fecal blood.” OR “Perirectal area inflflamed; no ulcerations, warts, or discharge. Unable to exam ine external sphincter, rectal vault, or prostate because of spasm of external sphincter and marked inflflammation and tenderness of anal canal.” These findings suggest proctitis from infectious cause OR “No perirectal lesions or fifissures. External sphincter tone intact. Rectal vault without masses. Left lateral prostate lobe with 1 × 1 cm fifirm, hard nodule; right lateral lobe smooth; median sulcus obscured. Stool brown; no fecal blood.” These findings are suspicious for prostate cancer.
- A protuberant abdomen with bulging flanks is suspicious for ascites, the most common complication of Cirrhosis. Because ascitic fluid characteristically sinks with gravity, whereas gas-filled loops of bowel rise, dullness appears in the dependent areas of the abdomen. Percuss for dullness outward in several directions from the central area of tympany. Map the border between tympany and dullness FIGURE 11-33. Percuss outward to map dullness from ascites Ascites reflects the increased hydrostatic pressure in cirrhosis (the most common cause of ascites), heart failure, constrictive pericarditis, or inferior vena cava or hepatic vein obstruction. It may signal decreased osmotic pressure in nephrotic syndrome, malnutrition, or ovarian cancer.
- Two additional techniques help to confirm ascites, although both signs may be misleading. FIGURE 11-34. Percuss for shifting dullness (here patient turned to right side) Test for shifting dullness Percuss the border of tympany and dullness with the patient supine, then ask the patient to roll onto one side. Percuss and mark the borders again. In a person without ascites, the border between tympany and dullness usually stays relatively constant. In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top.
- Test for a fluid wave Ask the patient or an assistant to press the edges of both hands firmly down the midline of the abdomen. This pressure helps to stop the transmission wave through fat. While you tap one flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through the fluid. Unfortunately, this sign is often negative until ascites is obvious, and it is sometimes positive in people without ascites An easily palpable impulse suggests ascites. A positive fluid wave, shifting dullness, and peripheral edema makes the presence of ascites to three to six times more likely.
- Identifying an Organ or Mass in an Ascitic Abdomen Try to ballotte the organ or mass, exemplified here by an enlarged liver Straighten and stiffen the fingers of one hand together, place them on the abdominal surface, and make a brief jabbing movement directly toward the anticipated structure. This quick movement often displaces the fluid so that your fingertips can briefly touch the surface of the structure through the abdominal wall
- Appendicitis is a common cause of acute abdominal pain. Assess carefully for the peritoneal signs of acute abdomen and the additional signs of McBurney point tenderness, Rovsing sign, the psoas sign, and the obturator sign described on the next page. Ask the patient to point to where the pain began and where it is now. Ask the patient to cough to see where pain occurs. Palpate carefully for an area of local tenderness. Classically,“McBurney point” lies 2 inches from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus Palpate the tender area for guarding, rigidity, and rebound tenderness. Early voluntary guarding may be replaced by involuntary muscular rigidity and signs of peritoneal inflammation. There may also be RLQ pain on quick withdrawal or deferred rebound tenderness. Palpate for Rovsing sign and referred rebound tenderness. Press deeply and evenly in the LLQ. Then quickly withdraw your fingers. Pain in the RLQ during left-sided pressure is a positive Rovsing sign. Assess the psoas sign. Place your hand just above the patient’s right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then extend the patient’s right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it. Increased abdominal pain on either maneuver is a positive psoas sign, suggesting irritation of the psoas muscle by an inflamed appendix. Though less helpful, assess the obturator sign. Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. Right hypogastric pain is a positive obturator sign, from irritation of the obturator muscle by an inflamed appendix. This sign has very low sensitivity. Perform a rectal examination and, in women, a pelvic examination. These maneuvers have low sensitivity and specificity, but they may identify an inflamed appendix atypically located within the pelvic cavity or other causes of the abdominal pain. Right-sided rectal tenderness may also be caused by an inflamed adnexa or seminal vesicle. Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign, and the psoas sign; it is three times more likely if there is McBurney point tenderness. The pain of appendicitis classically begins near the umbilicus, then migrates to the RLQ. Older adults are less likely to report this pattern Localized tenderness anywhere in the RLQ, even in the right flank, suggests appendicitis.
- When RUQ pain and tenderness suggest acute cholecystitis, assess Murphy sign. Hook your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Alternatively, palpate the RUQ with the fingers of your right hand near the costal margin. If the liver is enlarged, hook your thumb or fingers under the liver edge at a comparable point. Ask the patient to take a deep breath, which forces the liver and gallbladder down toward the examining fingers. Watch the patient’s breathing and note the degree of tenderness. A sharp increase in tenderness with inspiratory effort is a positive Murphy sign. When positive, Murphy sign triples the likelihood of acute cholecystitis
- 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, but should not be confused with diastasis recti, which is a benign 2- to 3-cm gap in the rectus muscles often seen in obese and postpartum patients. Epigastric hernias are defects in the abdominal wall located between the umbilicus and the xiphoid process. These hernias are usually small but may be associated with multiple defects. They result from multiple factors, including muscle weakness, congenitally weakened epigastric fascia, or increases in intra-abdominal pressure. Epigastric hernias rarely contain bowel and usually contain portions of the omentum or falciform ligament. Given the rarity of incarceration, repair of an epigastric hernia is indicated for symptomatic patients only. Laparoscopic repair can be attempted, but this type of hernia usually can be managed with a small incision where the defect is closed with interrupted sutures Umbilical hernias may be congenital or acquired. Umbilical hernias are common in newborns, especially in premature infants. Closure of an umbilical defect occurs after birth as the muscles of the rectus abdominis grow toward one another. Most umbilical hernias close spontaneously by 5 years of age and can be monitored as they will spontaneously resolve. Indications for repair include incarceration, symptomatic hernia, failure to decrease in size or if the defect fails to close by the age of 5 years In adults umbilical hernias form because of increased abdominal pressure due to pregnancy, obesity, or ascites. Females are at higher risk for this type of hernia than men. Small, asymptomatic hernias may be followed clinically. However, if an umbilical hernia enlarges in size, causes symptoms, or incarcerates surgical treatment should be offered. Hernias can be repaired laparoscopically or with an open procedure. Mesh should be employed for large defects where the fascial edges cannot be approximated without tension. In this case, mesh should be placed as a sublay technique (below the fascia) and sutured in place to prevent migration. Hernias that occur along the arcuate line are known as Spigelian hernias While rare, these hernias form due to the anatomic weakness of lack of a posterior rectus sheath below the arcuate line. As the hernia develops, peritoneum that passes through the arcuate line will pass laterally toward the external oblique muscle given the overlying aponeurosis Most patients present with pain and swelling in the mid to lower abdomen. Incarceration is common as up to 20% of patients present with a nonreducible hernia. Given the high rate of incarceration, surgical repair is usually recommended. Either open or laparoscopic repair can be performed. The defect is closed by approximating the medial and lateral edges of the transversalis fascia to the rectus sheath. Hernias that develop at sites of previous abdominal incisions are known as incisional hernias. Hernias can develop at the site of any previous abdominal incision. Up to 20% of midline incisions will develop hernias eventually. Vertical incisions may have a higher risk of hernia formation than transverse or oblique incisions. Upper abdominal incisions are also at higher risk than lower incisions. Laparoscopic port sites may also develop hernias. The etiology of incisional hernias is complex. Several patient derived factors increase the risk of hernia, including diabetes, immunosuppressant use, obesity, smoking, malnutrition, and connective tissue disorders. Local operative factors may also be implicated, including technique, wound infection, or high tension at the time of closure. Hernias can develop up to 10 years after surgery but normally occur in the early postoperative period. Incisional hernias can present as asymptomatic bulges or with severe discomfort. Multiple hernias can be present along the length of the incision. Elective surgery should be recommended in patients who are symptomatic. Small defects pose a higher risk of incarceration and should be repaired. To improve operative outcome, patient associated factors, including smoking and obesity, should be remedied prior to surgical repair.
- Occasionally, there are masses in the abdominal wall rather than inside the abdominal cavity. Ask the patient either to raise the head and shoulders or to strain down, thus tightening the abdominal muscles. Feel for the mass again. A mass in the abdominal wall remains palpable; an intra-abdominal mass is obscured by muscular contraction.