Abdominal examination

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Abdominal examination and potential findings Abdominal Exam.pdf
Abdominal examination and potential findings
Abdominal examination
Abdominal examination illustration.jpg
Abdominal examination The abdominal exam, in medicine, is performed as part of a physical examination, or when a patient presents with abdominal pain or a history that suggests an abdominal pathology
Purposeas part of a comprehensive physical exam

An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. The physical examination typically occurs after a thorough medical history is taken, that is, after the physician asks the patient the course of their symptoms. The abdominal examination is conventionally split into four different stages: first, inspection of the patient and the visible characteristics of their abdomen. Auscultation (listening) of the abdomen with a stethoscope. Palpation of the patient's abdomen. Finally, percussion (tapping) of the patient's abdomen and abdominal organs. [1] Depending on the need to test for specific diseases such as ascites, special tests may be performed as a part of the physical examination. [2] An abdominal examination may be performed because the physician suspects a disease of the organs inside the abdominal cavity (including the liver, spleen, large or small intestines), or simply as a part of a complete physical examination for other conditions. In a complete physical examination, the abdominal exam classically follows the respiratory examination and cardiovascular examination. [3]

Contents

The information gathered from the physical examination of the abdomen, along with the information from the history, are used by the physician to generate a differential diagnosis and ultimately a treatment plan for the patient.

Purpose

The purpose of the abdominal exam is to get more information that could indicate what is causing the patient's symptoms. The physician gains information by inspecting, auscultating, palpating, and percussing the abdomen. [3]

Positioning and environment

A suggested position is for the patient to be supine (on their back), with their arms to their sides. The patient should be placed in an environment with good lighting, and should be draped with towels or sheets to preserve privacy and warmth. [2] The patient's hips and knees should be flexed (in a bent position) so that their abdominal muscles remain relaxed during the examination. [4] Asking the patient to indicate areas that may be tender or painful is recommended to avoid exacerbating the pain during inspection and to increase the patient's comfort. [3]

Although physicians have had concern that giving patients pain medications during acute abdominal pain may hinder diagnosis and treatment, separate systematic reviews by the Cochrane Collaboration [5] and the Rational Clinical Examination [6] refute this.

Inspection

Although it may not seem very important, the doctor is actually gaining a lot of information when looking at the abdomen during an exam and can pick up important indications that something may be going on below the surface.

First, the doctor looks at the surface, outline, and movements of the abdomen, checking to see if there is anything odd or out of the ordinary.

Looking at the skin, the doctor is looking for anything abnormal like scars, stretch marks, lesions, dilated veins, or rashes.

The doctor then determines the shape of your abdomen, looking for any bumps, abdominal distension, or depressions. The doctor will also check your belly button for abnormalities like a hernia.

Finally, the doctor will look at the movement of the abdomen checking specifically for waves or odd flexing. [7]

Auscultation

Auscultation refers to the use of a stethoscope by the examiner to listen to sounds from the abdomen.

Unlike other physical exams, auscultation is performed prior to percussion or palpation, as both of these could alter the regularity of bowel sounds. [3]

Some controversy exists as to the length of time required to confirm or exclude bowel sounds, with suggested durations up to seven minutes. Bowel obstruction may present with grumbling bowel sounds or high-pitched noises. Healthy persons can have no bowel sounds for several minutes [8] and intestinal contractions can be silent. [9] Hyperactive bowel sounds may be caused by partial or complete bowel obstruction as the intestines initially try to clear the obstruction. [10] Absence of sounds may be caused by peritonitis, paralytic ileus, late-stage bowel obstruction, intestinal ischemia or other causes. [11] Some authors suggest that listening at a single location is enough as sounds can be transmitted throughout the abdomen. [12]

A prospective study published in 2014 where 41 physicians listened to the bowel sounds of 177 volunteers (19 of which had bowel obstructions and 15 with an ileus) found that "Auscultation of bowel sounds is not a useful clinical practice when differentiating patients with normal versus pathologic bowel sounds. The listener frequently arrives at an incorrect diagnosis. Agreement between raters was also low (54%).". [13] This article suggests focusing on other indicators (flatus, pain, nausea) instead. There is no research evidence that reliably corroborates the assumed association between bowel sounds and gastro-intestinal motility status. [14]

The examiner also typically listens to the two renal arteries for abnormal blood flow sounds (bruits) by listening in each upper quadrant, adjacent to and above the umbilicus. Bruits heard in the epigastrium that are confined to systole are considered normal. [3]

Palpation

Examination of the abdomen of a child. Physical examination of child, age 15 months.jpeg
Examination of the abdomen of a child.

The examiner should first talk to the patient and explain what this part of the examination will involve. [4] He or she will typically palpate all nine areas of the patient's abdomen, and being mindful of areas of discomfort, begin by palpating areas of no pain. This is typically performed twice, first with light pressure and then with deeper pressure to better exam the abdominal organs.

On light palpation, the examiner tests for any palpable mass, rigidity, or pain on the surface.

On deep palpation, the examiner is testing for any organomegaly (enlarged organs.) Typically, the clinician is looking for enlargement of the liver and spleen or abnormal masses in the intestines. Sometimes the physician looks for the kidney and uterus as well. [10]

Reactions that may indicate pathology include:

Percussion

Percussion can be performed in all four quadrants of the abdomen and may reveal a painful response by the patient. During the abdominal examination, percussion may allow the estimation of location and quantity of gas, hard or soft masses, and sizes of certain organs, such as the liver and the spleen. Abnormal findings may include splenomegaly, hepatomegaly and urinary retention.

Organomegaly of the liver and the spleen can be appreciated by percussing in a particular manner:

Examination of the spleen may reveal Castell's sign or alternatively Traube's space.

Dull sounds on the abdomen could suggest pregnancy, an ovarian tumor, a distended bladder, hepatomegaly or splenomegaly. Dullness on either side of the abdomen could suggest ascites. Some other areas of the abdomen may sound dull suggesting that there may be some fluid or feces. The dullness of the liver can be appreciated by percussing at the edge of the lower chest right above the costal margins. The resonant sounds of gastric air bubbles can be appreciated at the left side. In rare cases, when organs are reversed as is the case in situs inversus, resonant (hollow) sounds would be expected on the right side and liver dullness on the left. [3]

Other tests and special maneuvers

Special maneuvers may also be performed, to elicit signs of specific diseases. These include

Related Research Articles

Bowel obstruction Human disease

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.

Auscultation listening to the internal sounds of the body, usually using a stethoscope

Auscultation is listening to the internal sounds of the body, usually using a stethoscope. Auscultation is performed for the purposes of examining the circulatory and respiratory systems, as well as the alimentary canal.

Abdominal pain Stomach aches

Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues.

Ileus Human disease characterized by impairment of intestinal peristalsis; in modern language usually excludes mechanical bowel obstruction

Ileus is a disruption of the normal propulsive ability of the intestine due to the malfunction of peristalsis. Ileus originally referred to any lack of digestive propulsion, including bowel obstruction, but current medical usage restricts its meaning only to those disruptions caused by the failure of the system's peristalsis and excludes failures due to mechanical obstruction, with the exception of certain older terms such as "gallstone ileus" and "meconium ileus" which are still accepted as correct due to their persistence in usage.

Rovsings sign

Rovsing's sign, named after the Danish surgeon Niels Thorkild Rovsing (1862–1927), is a sign of appendicitis. If palpation of the left lower quadrant of a person's abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing's sign and may have appendicitis.

Palpation process of using ones hands to examine the body, especially while perceiving/diagnosing a disease or illness

Palpation is the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness. Usually performed by a health care practitioner, it is the process of feeling an object in or on the body to determine its size, shape, firmness, or location.

Colic in horses is defined as abdominal pain, but it is a clinical symptom rather than a diagnosis. The term colic can encompass all forms of gastrointestinal conditions which cause pain as well as other causes of abdominal pain not involving the gastrointestinal tract. The most common forms of colic are gastrointestinal in nature and are most often related to colonic disturbance. There are a variety of different causes of colic, some of which can prove fatal without surgical intervention. Colic surgery is usually an expensive procedure as it is major abdominal surgery, often with intensive aftercare. Among domesticated horses, colic is the leading cause of premature death. The incidence of colic in the general horse population has been estimated between 4 and 10 percent over the course of the average lifespan. Clinical signs of colic generally require treatment by a veterinarian. The conditions that cause colic can become life-threatening in a short period of time.

Percussion is a method of tapping on a surface to determine the underlying structures, and is used in clinical examinations to assess the condition of the thorax or abdomen. It is one of the five methods of clinical examination, together with inspection, palpation, auscultation, and inquiry. It is done with the middle finger of one hand tapping on the middle finger of the other hand using a wrist action. The nonstriking finger is placed firmly on the body over tissue. When percussing boney areas such as the clavicle, the pleximeter can be omitted and the bone is tapped directly such as when percussing an apical cavitary lung lesion typical of TB.

Respiratory examination

A respiratory examination, or lung examination, is performed as part of a physical examination, in response to respiratory symptoms such as shortness of breath, cough, or chest pain, and is often carried out with a cardiac examination.

Abdomen frontal part of the body between the thorax (chest) and pelvis

The abdomen is the part of the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen is the front part of the abdominal segment of the trunk. The region occupied by the abdomen is called the abdominal cavity. In arthropods it is the posterior tagma of the body; it follows the thorax or cephalothorax.

An abdominal mass is any localized enlargement or swelling in the human abdomen. Depending on its location, the abdominal mass may be caused by an enlarged liver (hepatomegaly), enlarged spleen (splenomegaly), protruding kidney, a pancreatic mass, a retroperitoneal mass, an abdominal aortic aneurysm, or various tumours, such as those caused by abdominal carcinomatosis and omental metastasis. The treatments depend on the cause, and may range from watchful waiting to radical surgery.

Traubes space

Traube's (semilunar) space is an anatomic space of some clinical importance. It is a crescent-shaped space, encompassed by the lower edge of the left lung, the anterior border of the spleen, the left costal margin and the inferior margin of the left lobe of the liver. Thus, its surface markings are respectively the left sixth rib superiorly, the left mid axillary line laterally, and the left costal margin inferiorly.

Castells sign

Castell's sign is a medical sign assessed to evaluate splenomegaly and typically part of an abdominal examination. It is an alternative physical examination maneuver to percussion over Traube's space.

Obturator sign indicator of irritation to the obturator internus muscle

The obturator sign or Cope's obturator test is an indicator of irritation to the obturator internus muscle.

An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate surgical treatment.

Distal intestinal obstruction syndrome

Distal intestinal obstruction syndrome (DIOS) involves obstruction of the distal part of the small intestines by thickened intestinal content and occurs in about 20% of mainly adult individuals with cystic fibrosis. DIOS was previously known as meconium ileus equivalent, a name which highlights its similarity to the intestinal obstruction seen in newborn infants with cystic fibrosis. DIOS tends to occur in older individuals with pancreatic insufficiency. Individuals with DIOS may be predisposed to bowel obstruction, though it is a separate entity than true constipation.

Abdominal guarding is the tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the abdominal wall is pressed. Abdominal guarding is also known as 'défense musculaire'.

Abdominal trauma injury to the abdomen

Abdominal trauma is an injury to the abdomen. Signs and symptoms include abdominal pain, tenderness, rigidity, and bruising of the external abdomen. Complications may include blood loss and infection.

The cardiovascular examination is a portion of the physical examination that involves evaluation of the cardiovascular system. The exact contents of the examination will vary depending on the presenting complaint but a complete examination will involve the heart, lungs, belly and the blood vessels.

Spleen pain

Spleen pain is a pain felt from the left upper quadrant of the abdomen or epigastrium where the human spleen is located or neighboring.

References

  1. "UCSD's Practical Guide to Clinical Medicine". meded.ucsd.edu. Retrieved 2019-09-01.
  2. 1 2 Seidel, Henry M.; Ball, Jane W.; Dains, Joyce E.; Flynn, John A.; Solomon, Barry S.; Stewart, Rosalyn W. (2011). Mosby's Guide to Physical Examination (7th ed.). St. Louis, MO: Elsevier. pp. 492–513. ISBN   978-0-323-05570-3.
  3. 1 2 3 4 5 6 MD, Lynn B. Bates' Guide to Physical Examination and History-Taking, 11th Edition. Lippincott Williams & Wilkins, 11/2012.
  4. 1 2 3 4 5 Greenberger, NJ (2016). "Part IV - Approach to the Patient at the Bedside: Acute Abdominal Pain". Principles and Practice of Hospital Medicine. AccessMedicine: McGraw-Hill.
  5. Manterola C, Vial M, Moraga J, Astudillo P (2011). Manterola C (ed.). "Analgesia in patients with acute abdominal pain". Cochrane Database of Systematic Reviews (1): CD005660. doi:10.1002/14651858.CD005660.pub3. PMID   21249672.
  6. Ranji SR, Goldman LE, Simel DL, Shojania KG (2006). "Do opiates affect the clinical evaluation of patients with acute abdominal pain?". JAMA. 296 (14): 1764–74. doi:10.1001/jama.296.14.1764. PMID   17032990.
  7. Bates, Barbara, 1928-2002. (1982), A Visual guide to physical examination., Lippincott, OCLC   16319335 CS1 maint: multiple names: authors list (link)
  8. McGee, S, Evidence-Based Physical Diagnosis, 3rd Edition. Philadelphia, PA: Elsevier-Saunders; 2012
  9. "Listening to Bowel Sounds: An Outdated Practice?". March 2017.
  10. 1 2 Mendiratta, Vicki; Lentz, Gretchen M. (2017). "History, Physical Examination, and Preventative Health Care - Abdominal Exam". Comprehensive Gynecology. ClinicalKey: Elsevier, Inc.
  11. Jarvis, C.(2008). Physical Examination and Health Assessment. 5th edn. Saunders Elsevier, St Louis
  12. Reuben, A. (2016). Examination of the abdomen. Clinical Liver Disease, 7(6), 143–150. doi:10.1002/cld.556
  13. Felder, S., Margel, D., Murrell, Z., & Fleshner, P. (2014). Usefulness of Bowel Sound Auscultation: A Prospective Evaluation. Journal of Surgical Education, 71(5), 768–773. doi:10.1016/j.jsurg.2014.02.003
  14. Massey RL. Return of bowel sounds indicating an end of postoperative ileus: is it time to cease this long-standing nursing tradition? Medsurg Nurs . 2012;21(3):146–150
  15. 1 2 3 4 Fasen, Geoffrey; Schirmer, Bruce; Hedrick, Traci L. "Appendix: Abdominal Exam". Shackelford's Surgery of the Alimentary Tract. ClinicalKey: Elsevier, Inc. pp. 1951–1958.