Abdominal Exam for Advanced Practice

CESAP/PACR

2012

Outline

• History• Risk• Examination• Abnormal Findings/Differential Diagnoses• Variants for Children• Variants for Elderly and Pregnancy

History

• Presenting complaint• Area, origin, pattern, duration, onset of

symptom?• Associated Symptoms• Menstrual/Sexual History?• PMH (surgical history, medications)• Other (Nutrition, Diet, ETOH/Drugs, Stress,

Travel)

GI/GU Specific• Pain/Discomfort• Urinary habits• Nausea/vomiting/diarrhoea• Bleeding• Anorexia• Gyn/Ob history• What else???????

Bowel habits– http://www.youtube.com/watch?v=jsVgi8hoFFc

• Ask the patient about bowel movements

– Frequency of the bowel movements

– Consistency of the bowel movements (diarrhea vs. constipation)

– Any pain with bowel movements

– Any blood or black, tarry stool (meleana) with the bowel movement

– Ask about the color of the stools (white or gray stools can indicate liver or gallbladder disease)

– Look for any associated signs such as jaundice or icteric sclerae

Risk Factors

• BMI (over or under?)• Health Behaviours (ETOH, Drugs, Crash

Diets, Medications)• Chronic Disease

– Modifiable (change in peristalsis?)– Non-Modifiable (medications, inactivity, family

history)

Preparing for Exam

• Stethoscope• Full exposure to abdomen however

maintain appropriate draping• Have patient lie supine with arms at sides,

legs slightly bent

Anatomy of the abdominal GI tract

LandmarksMusculatureVasculatureVital Organs

Kidneys• Described as posterior organs• The upper poles are protected by ribs

• Costovertebral angle/ Renal angle This is the angle formed by the 12th rib &

transverse process of the upper lumber vertebrae.

Pain in Abdominal Areas

Types of Visceral Pain

History Taking of Problems of the Abdomen: GI Tract

• Qualify the patient’s pain

– Visceral pain: when hollow organs (stomach, colon) forcefully contract or become distended. Solid organs (liver, spleen) can also generate this type of pain when they swell against their capsules. Visceral pain is usually gnawing, cramping, or aching and is often difficult to localize (hepatitis)

– Parietal pain: when there is inflammation from the hollow or solid organs that affect the parietal peritoneum. Parietal pain is more severe and is usually easily localized (appendicitis)

– Referred pain: originates at different sites but shares innervation from the same spinal level (gallbladder pain in the shoulder)

Review of Systems-Tips

• Remember these are subjective findings you ask the patient

• Questions often pertain to symptoms but also to common diseases related to the system you are examining

• Start with a generic question “How is your digestion?” or “How about your bowels?”

• The goal is to uncover problems the patient may have overlooked.

Examination

• Inspection• Auscultation• Palpation• Percussion

Examination• Consider landmarks• Four quadrants/ Nine

regions• 1. Epigastric,

2.Umbilical, 3.Suprapubic, 4&5.Right and Left hypochandriac,

• 6&7. lumbar • 8&9. inguinal areas

Landmarks

Systemic Inspection

• Inspection should include looking for signs of chronic disease overall:

• Nail beds/palms of hands• Skin/hair• mucous membranes (mouth and anus)• eyes

Focused Inspection• Contour of abdomen-

– Rounded? Protuberant? Scaphoid? Flat?• Skin characteristics-

– lesions, hernia, scars, striae, tattoos, echymosis, hair distribution

• Other– gravid, ascites, nodules– Aortic pulsations, peristalsis, movement, vein

visibility

Inspection

Inspection

Inspection

Palpation• One or two handed technique.

Use finger pads not tips

• Watch facial expressions!

• Palpate in three phases: light, deep and during respiration– Light for tenderness. – Deep palpation of organs and

to detect masses/tenderness.– Palpate during respiration to

feel for “shifting” of organs with breathing.

Palpation

• Assess organs, muscle spasms, masses, fluids and tenderness (6 F’s)

• Check umbilical ring (round and no abnormalities)

Palpation of LiverPalapation of the liver should be performed by placing your hand on the right upper quadrant, with index finger in line with the costal angle. Ask patient to breath in and push hand inwards and upwards. A liver edge should be felt.

Palpation of the kidneys

To examine the kidneys place hand on right side of abdomen below the costal margin, above the umbilicus and the left hand under the back below the liver. Press firmly up with the left hand and down with right. Repeat on the left hand side. If enlarged the kidney will be palpable.

Renal angle

• Percuss the renal angle with your fist with moderate force.

Palpating the Spleen

A spleen is not palpable unless it is enlarged. Use your left hand under left lower rib cage, position finger tips so they point to axilla and press inwards and upwards. You can also ask the patient to take a deep breath and feel again.

Abdominal Reflexes • Lightly but briskly stroke each side of the

abdomen using a key or tip of wooden applicator (Tests T8-10 (above the umbilicus) and T10-12 (below the umbilicus)

• Note the contraction of the abdominal muscles and the deviation of the umbilicus towards the stimulus

• If reflex diminished could be related to obesity or pregnancy

Auscultation of Vascular Sounds

Palpating the Aorta

Percussion• Systematic route• To assess size and

density of organs• To distinguish gas,

ascites, cystic or solid masses

• Tympany= air. Usually high pitched/musical

• Dullness=organs or masses. Short, high-pitched with little resonance.

Percussion of liver• When percussing the liver you are

measuring it’s size, start at the right mid-clavicular line where you will start with lung resonance and percuss down the sound changes to dullness. Then percuss up starting in the mid clavicular line level with umbulicius and note where the sound changes. Measure between these two points .

Percussion of Liver

• Important to define borders, especially in diseased patient

• Normal measurement 6-12cm in adult• Check for nodules, tenderness,

irregularities• Report liver size via span and extent of

projection from costal margin.

Percussion of Spleen

• Percuss for dullness as usually tympanic! (so if hear dullness (+) finding!)

• Typically from 6th to 10th rib• Have patient inspire while percussing….if

spleen enlarged, tympany changes to dullness

Percussion• Abnormal findings

Auscultation• Use diaphragm for bowel sounds• Use bell for vasculature sounds…bruits, friction

rubs, venous hum• Listen for clicks/gurgles: “borborygmi”…5-35 per

minute. Usually more active after meal.• Absence of sounds established only after 3

minutes of continuous listening.

• *Should be done prior to percussion/palpation as bowel sounds may change with manipulation

Auscultation• Absent bowel sounds indicate ileus• Increased bowel sounds (including high-

pitched tinkling or marked borborygmi) indicate obstruction, bleed, malabsorption, carcinoid syndrome

Abnormal Findings/Differential Diagnoses• Cholecystitis….+ Murphy sign (cessation of

inspiration with palpitation of gallbladder.)• Pancreatitis, epigastric tenderness or ectopic

pregnancy, +Cullen sign (ecchymosis around umbilicus.)

• Alcoholic Hepatitis…palpate an enlarged liver with marked tenderness

• Dysphagia....complaint of pain in the throat or chest region indicates oesophageal disorder.

Abnormal Findings/Differential Diagnoses• Costovertebral angles for kidney tenderness…indicates

renal disease/pyleonephritis• Suprapubic tenderness typical with cystitis• Ascities…percuss for shifting dullness and/or test for

fluid wave (often found too late)• Appendicitis….check for rebound tenderness (Romberg

sign), guarding, McBurney’s sign, Psoas sign, Obturator sign

Exam of the Anus, Rectum and Prostate

Risk Factors

• Health Behaviours (ETOH, Drugs, Crash Diets, Medications)

• Chronic Disease– Modifiable (Drugs, depression, stress,

inactivity)– Non-Modifiable (medications, neurologic

disorders, family history)

Anus, Rectum and Prostate• Terminal portions of GI tract• Sphincter/ring muscles internally and externally

in anus• Mucosal tissue• Anus controls excretion of faeces, rectum stores

it• Rectum continuous with sigmoid colon• Prostate located at base of bladder/surrounds

the urethra. Composed of muscular and glandular tissues. Responsible for secretion

Review History• Change in patterns, consistency, colour,

odour, flatus, pain, nausea, fever, distension, change in urinary function, hesitancy, nocuturia, dysuria, dripping/dribbling, urethral discharge?

• For exam…….consider patient position…side lying, knee-chest, standing…or perform during pelvic

Don’t Omit This Exam

• Due to patient discomfort, examiner discomfort…..this exam is often omitted inappropriately!

• Important to the overall clinical examination of the alimentary tract, genito-urinary tract and more! (back pain, anaemia, unexplained weight loss, etc)

Exam• Inspect for haemorrhoids, skin tags, condyloma,

lesions, fissures/fistulas….then patient needs to bear down…look for same as well as polyps, prolapse.

• Use clock references• Palpation of external • PR…go slowly and warn patient. Use lubricant.• Palpation of internal

– muscle tone/anal sphincter ring. – Should feel smooth/even pressure. – Feel post/lateral walls for nodules, masses, pain. – Test any stool retrieved for guaiac.

Exam• Prostate exam – warn pt may feel urge to

urinate. Note size, shape, consistency. Normal feels similar to eraser/4cm. Should be slightly mobile and not tender! Lobes should be symmetric

• Stimulation of prostate could cause urethral discharge…….if so culture sample!

Abnormal Findings/Differential Diagnoses• Bloody stools (bright red vs. black)

….haemorrhoids, ulcer, carcinoma.• Steatorrhea….indicative of malabsorption

syndrome or CF• Large, tender, purplish-blue lesions around

external sphincter……thrombosed haemorrhoids

• Benign hypertrophy…usually boggy. Carcinoma usually hard and nodular

Abnormal Findings

Abnormal Findings

Abnormal Findings

Abnormal Findings

Variants for Paediatrics• In newborns- abdomen should be rounded…any

concavity or distension considered abnormal – check umbilicus….note any protrusion/hernia– Infants/children swallow more air….expect more tympany– Palpation easier if infant sucking (muscles will relax)– Liver palpable 1-2cm below costal margin, spleen usually not

palpable– Diastasis recti- a normal finding (separation of the medial rectus

sheath…visualize vertical outpouching at the midline)– 2 arteries/1 vein in umbilical cord

• In Toddlers- abdomen is last to “slim”…..Pot belly common– May be difficult to examine due to trust/ticklishness/fear– Common to fecal matter mass (hard round balls in LLQ)

Variants for Paediatrics

• School Age Children- similar to adult exam– Spleen enlargement common in viral illnesses

• Rectal exam not necessary on children/infants unless problem

Variants for Elderly• Consider positioning for patient….can they

comfortably lie supine?• Elderly….abdominal wall is thinner so usually

easier to feel. • Constipation a frequent complaint in elderly due

to decreased intestinal motility. • Sphincter tone may be decreased. • Older males typically have enlarged prostate…

should feel smooth, rubbery and symmetric.• Screening faecal occult, sigmoidoscopy and

colonoscopy recommended after age 50.

Variants for Pregnancy• Decreased bowel sounds normal. • Constipation common due to hormonal

changes. • Linea nigra and striae normal findings. • Top of uterus palpable at level of the

umbilicus at 20 weeks.• Difficult to identify abdominal masses in

later stages of pregnancy

References• Hogan-Quigley,B; Palm,M;Bickley,L (2012) Nursing

Guide to Physical Examination and History Taking. Lippincott, Williams & Wilkins.

• Bickley,L; (2009) A Guide to Physical Examination and History Taking (10th Ed) Lippincott, Williams & Wilkins.

• Royal College of Surgeons. http://www.edu.rcsed.ac.uk/• Seidel, H., Ball, J., Dains, J., Benedict, G.(1995)Mosby’s

Guide to Physical Examination. (3rd Edition)• Browes,N et al (2005) Browse’s introduction to the

symptoms and signs of surgical disease. 4th Ed. London