OnExam

Vital Signs

For abdominal problems, it is important to have an accurate, up-to-date set of vitals available. Follow the directions for assessing vital signs.

Setting Up

The fidelity of the abdominal examination can be improved by taking the following into account:
  • Assume the patient is supine unless otherwise stated.
  • Drape the patient appropriately exposing the abdomen from below the breasts (or nipples on males) to the pubic symphysis.
  • Ask the patient to put their arms to their side to prevent stretching of abdominal skin.
  • Ensure that the patient is relaxed to prevent guarding.
  • Ask the patient to point to areas of pain.
  • Ask the patient to empty their bladder to prevent uncontrolled urination or the incorrect finding of abdominal mass in the suprapubic area.

Inspection

  • Stigmata of liver disease
    • Caput medusae
      Dilated superficial veins near umbilicus
    • Scleral icterus
      Yellowing of sclera/jaundice See Image
    • Spider angiomas
      Central red arteriole with capillaries extending outward See Image
    • Gynecomastia
      Enlarged breasts in males
    • Palmar erythema
      Reddening of palms
    • Dupuytren’s contracture in the hand
      Flexion contracture of fingers towards palm of hand
  • Abdominal countour
    • Obese
    • Thin or Emaciated
    • Distended
    • Scaphoid
  • Bulging flanks or protuberant abdomen
    • Observed from foot of bed
    • Sign of ascites with a sensitivity or 73–93% and a specificity of 44-70%
  • Visible peristalsis
  • Masses or bulges
    • If mass/bulge is present, ask patient to raise head and shoulders off examining table; accentuates hernias
  • Rashes
  • Lesions
  • Striae
  • Clubbing and schamroth sign
  • Intra-abdominal/retroperitoneal bleeding
  • Scars
    • May indicate previous surgeries
  • Pulsations
    • Can be normal in lean individual
    • May indicate an abdominal aortic aneurysm
  • Peripheral edema

Auscultation

  • Auscultate before percussion or palpation to prevent the alteration of bowel sounds
  • Stethoscope instructions
    • Bell – low-frequency sounds; rest the bell lightly on the patient
    • Diaphragm – high-frequency sounds; use firm contact pressure
    • Stethoscopes with one functional side: apply light pressure for bell mode and firm pressure for diaghragm mode
  • Listen for bowel sounds
    • Normal = 5-30 irregular gurgles/minute at varying pitches and intensity
    • Listen in one location (e.g., LUQ) with diaphragmn of stethoscope until bowel sounds are heard or up to 1 minute
    • Note frequency and characteristics (i.e. borborygmi of hyperperistalsis)
  • Bruits
    • Auscultate for bruits over the abdominal aorta, renal arteries, iliac arteries, and femoral arteries
    • As bruits may be high or low pitched, the bell of the stethoscope should be used (as the diaphragm would have picked up bruits during the bowel sounds assessment).
    • If a bruit is heard it is a sign of turbulent blood flow in an artery (i.e occlusion or arterial insufficiency)
  • Friction rubs
    • Rarely heard
    • Grating sounds caused by respiratory motion over the inflamed peritoneal surface of a liver or spleen
    • Best heard with the diaphragm of the stethoscope

Percussion

  • Percuss the four quadrants of the abdomen noting areas of tympany and dullness
    • Tympany is normal
    • Dullness may be abnormal (mass) or normal (stool)
    • Tympany in periumbilical region and dullness in flanks may indicate ascites (May merit special tests, see Shifting Dullness and fluid Wave)
  • Liver span
    • Percuss upward along the right mid-clavicular line starting below the umbilicus (RLQ); note the point where dullness occurs
    • Percuss downward along the right mid-clavicular line starting at the nipple line; note the point where dullness occurs
    • Measure the distance between the two points of dullness
    • Normal adult liver span 6-12 cm at the mid-clavicular line
      • If hepatomegaly discovered (>6-12cm), repeat measurement in mid-sternal line.
    • Normal adult liver span 3-6cm at the mid-sternal line
    • If liver disease is suspected, consider doing tests for ascites
  • Spleen
    • Traube's Space
      • Triangular area bordered by costal margin inferiorly, anterior axillary line laterally, and the sixth rib superiorly
      • Percuss on inspiration and expiration, a change in resonance may signify splenomegaly
      • Normal percussion in Traube’s space is tympanic
      • Sensitivity: 62%; Specificity: 72%
    • Castell's Sign
      • Percuss lowest costal margin at anterior axillary line while patient fully inspires
      • If tympany changes with inspiration, may signify splenomegaly
      • Sensitivity: 82%; Specificity: 83%
  • Costovertebral Angle Tenderness
    • Ask patient to sit upright
    • Place ball of one hand on posterior costovertebral angle and strike with ulnar surface of other fist
    • Use enough force to elicit a perceptible but painless sound in a normal person
    • Pain may suggest nephritis or a musculoskeletal cause

Palpation

  • To maintain patient comfort always begin at the furthest point from tender location of pain
  • Ensure the patient is relaxed
  • Palpate lightly in all four quadrants
    • Feel for abdominal tenderness, rigidity, guarding (voluntary vs involuntary, masses, enlarged organs)
  • Palpate deeply in all four quadrants
    • Feel for abdominal tenderness, rigidity, guarding (voluntary vs involuntary), masses, enlarged organs)
    • Assess for incisional, inguinal or umbilical hernias
    • Assess for rebound tenderness
  • Liver
    • Place your left hand behind the patient on the 11th and 12th ribs to support the patient
    • Palpate upwards from the inferior border of the lower right quadrant along the midclavicular line
    • Have patient inhale deeply and exhale during each palpation
    • Feel for liver enlargement, firmness/tenderness, bluntness/rounding, or irregularities of the liver edge
    • The “Hooking Technique” may be helpful for obese patients
      • Stand facing the patient's feet
      • Place both hands side by side on patient's chest with fingers towards costal margin
      • Have the patient inhale deeply and attempt to palpate the liver as it slides past
    • Normally, the liver edge is palpable 3cm below the costal margin on inspiration
  • Spleen
    • Place your left hand across and behind the patient on the lower left ribs to provide support
    • Start palpating from the right lower quadrant towards the spleen
    • Have patient inhale deeply and exhale during each palpation
    • Feel for spleen enlargement or tenderness
      • May see splenic enlargement in portal hypertension, HIV infection, hematologic disease
    • Palpation of spleen for detecting hypersplenism has a specificity of 98% and sensitivity of 27%
  • Aorta
    • Use the fingertips of both hands, place them a few cm left of midline and above the umbilicus
    • Push deep and medially with increasing pressure.
    • If a pulsating mass is felt, try to characterize its size and consider ultrasound imaging
    • Greater than 3cm in diameter considered dilated
    • Greater than 5.5cm diameter considered high risk for rupture
    • Currently screening for AAA is only indicated for men between 65 and 75 who have ever smoked
    • Risk factors for AAA include age >65, history of smoking, male gender, 1st degree relative with AAA
    • Palpating aorta as a means of detecting AAA has a specificity of 56% and a sensitivity of 88%
  • Kidneys
    • Capturing a kidney on palpation is rare
    • The right kidney is more easily captured than the left
    • Use one hand to apply pressure just below the 12th rib in an attempt to bring the kidney forward.
    • Use the other hand to press lightly on the lateral anterior abdominal wall, creating a thick sandwich of tissue between the two hands
    • Ask the patient to take a deep breath and at peak inspiration, press more firmly in an attempt to squeeze
    • the kidney between the two hands
    • If it slides between your hands, make note of its size, contour, and any tenderness
  • Rectal exam
    • Instructions for performing a rectal exam can be found elsewhere
  • If appendicitis is suspected, consider doing the special tests for appendicitis such as
  • If cholecystitis or cholangitis is suspected, consider palpating for Murphy’s Sign
  • To differentiate between abdominal wall pain and intra-abdominal pathology consider doing Carnett’s Test

References

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