PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

AbdomenAbdomen

The abdomen is a large oval cavity extendinng from the diaphragm down to the brim of pelvis.

Surface landmarks of the abdomen:

Inside the abdominal cavity, all the internal organs are the viscera.

Solid viscera (those that maintain a characteristic shape):

liver

pancreas

spleen

adrenal glands

kidneys

ovaries & uterus

Hollow viscera (the shape depends on the contents):

stomach

gallbladder

small intestine

colon

bladder

Subjective data:

1. Appetite

2. Dysphagya

3. Food intolerance

4. Abdominal pain

5. Nausea/vomiting

6. Bowel habits

7. Past abdominal history

8. Medications

9. Nutritional assessment

Examiner asks (Rationale)

AppetiteAppetite•Any changes in appetite? Is this a loss of appetite?Any changes in appetite? Is this a loss of appetite?

•Any changes in weight? How much weight gained or lost? Any changes in weight? How much weight gained or lost? Over what time periodOver what time period

(Anorexia is a loss of appetite for food that occurs with GI (Anorexia is a loss of appetite for food that occurs with GI disease or is a side effect to some medications, with disease or is a side effect to some medications, with pregnancy, or with psychological disorders)pregnancy, or with psychological disorders)

Examiner asks (Rationale)

DysphagiaDysphagia

•Any difficulty swallowing? When did you Any difficulty swallowing? When did you first notice this?first notice this?

(Dysphagia occurs with disorders of the (Dysphagia occurs with disorders of the throat & esophagus)throat & esophagus)

Examiner asks (Rationale)Food intoleranceFood intolerance•Are there any foods you cannot eat? What happens if you Are there any foods you cannot eat? What happens if you do eat them: allergic reaction, heartburn, belching, bloatng, do eat them: allergic reaction, heartburn, belching, bloatng, indigestion?indigestion?

•Do you use antacids? How often?Do you use antacids? How often?

(FI, e.g., lactase deficiency resulting in bloating or excessive (FI, e.g., lactase deficiency resulting in bloating or excessive gas after taking a milk productsgas after taking a milk products

Pyrosis (heartburn), a burning sensation in esophagus & Pyrosis (heartburn), a burning sensation in esophagus & stomach, due to reflux of gastric acidstomach, due to reflux of gastric acid

Eructation (belching) ) Eructation (belching) )

Examiner asks (Rationale)Abdominal painAbdominal pain

•Any abdominal pain? Please point to itAny abdominal pain? Please point to it

•Is the pain in one spot or does it move around?Is the pain in one spot or does it move around?

•How did it start? How long have you had it?How did it start? How long have you had it?

•Constant or does it come & go? Occur before or after meals? Does Constant or does it come & go? Occur before or after meals? Does it peak? When?it peak? When?

•How would you describe the character: cramping (colic type), How would you describe the character: cramping (colic type), burning in pit of stomach, dull, stabbing, aching?burning in pit of stomach, dull, stabbing, aching?

•Is the pain relived by food, or worse after eating?Is the pain relived by food, or worse after eating?

•Is the pain associated with: menstrual period or irregularities, Is the pain associated with: menstrual period or irregularities, stress, dietary indiscretion, fatique, nausea & vomiting, gas, fever, stress, dietary indiscretion, fatique, nausea & vomiting, gas, fever, rectal bleeding, frequent urination, vaginal or penile discharge?rectal bleeding, frequent urination, vaginal or penile discharge?

•What makes the pain worse: food, position, stress, medication, What makes the pain worse: food, position, stress, medication, activity?activity?

•What have you tried to relieve pain: rest, haeting pad, change in What have you tried to relieve pain: rest, haeting pad, change in position, medication?position, medication?

Examiner asks (Rationale)Abdominal painAbdominal pain

(Abdominal pain may be (Abdominal pain may be visceralvisceral from an internal organ from an internal organ (dull, general, poorly localized), (dull, general, poorly localized), parietalparietal from inflammation from inflammation of overlying peritoneum (sharp, precisely localized, of overlying peritoneum (sharp, precisely localized, aggravated by movement), or aggravated by movement), or referredreferred from a disorder in from a disorder in another site)another site)

Examiner asks (Rationale)

Nausea/vomitingNausea/vomiting

•Any nausea or vomiting? How often? How much comes up? What is the Any nausea or vomiting? How often? How much comes up? What is the color? Is there an odor?color? Is there an odor?

(N&V is a common side effect of many medications and occurs with (N&V is a common side effect of many medications and occurs with gastrointestinal disease as well as early pregnancy.gastrointestinal disease as well as early pregnancy.

•Is it bloody?Is it bloody?

(Hematemesis occurs with stomach or duodenal ulcers and esophageal (Hematemesis occurs with stomach or duodenal ulcers and esophageal varices)varices)

•Is the nausea and vomiting associated with colicky pain, diarrhea, Is the nausea and vomiting associated with colicky pain, diarrhea, fever, chills?fever, chills?

•What food did you eat in the last 24 h? Where? At home, school, What food did you eat in the last 24 h? Where? At home, school, restaurant? Is there anyone else in the family with same symptoms in restaurant? Is there anyone else in the family with same symptoms in last 24 h?last 24 h?

(Consider food poisoning)(Consider food poisoning)

Examiner asks (Rationale)

Bowel habitsBowel habits

•How often do you have a bowel movement?How often do you have a bowel movement?

•What is the color? Consistency?What is the color? Consistency?

•Any diarrhea or constipation? How long?Any diarrhea or constipation? How long?

•Any recent change in bowel habits?Any recent change in bowel habits?

•Use laxatives? Which ones? How often do you use them?Use laxatives? Which ones? How often do you use them?

(Black stools may be tarry due to passage of occult blood (melena) (Black stools may be tarry due to passage of occult blood (melena) from GI bleeding or nontarry from injection of iron medicationsfrom GI bleeding or nontarry from injection of iron medications

Red blood in stools occurs whith GI bleeding or localized bleeding Red blood in stools occurs whith GI bleeding or localized bleeding aroun the anus)aroun the anus)

Examiner asks (Rationale)

Past abdominal historyPast abdominal history•Any past history of GI problems: ulcer, gallbladder disease, Any past history of GI problems: ulcer, gallbladder disease, hapatitis/jaundice, appendicitis, colitis, hernia?hapatitis/jaundice, appendicitis, colitis, hernia?

•Ever had any operations in the abdomen? Please describeEver had any operations in the abdomen? Please describe

•Any problems after surgery?Any problems after surgery?

•Any abdominal x-ray studies? How were the results?Any abdominal x-ray studies? How were the results?

Examiner asks (Rationale)

MedicationsMedications

•What medications are you currently taking?What medications are you currently taking?

•How about alcohol – how much would you say you drink How about alcohol – how much would you say you drink each day? Each week? When was your last alcoholic drink?each day? Each week? When was your last alcoholic drink?

•How about cigarettes – do you smoke? How many packs per How about cigarettes – do you smoke? How many packs per day? For how long?day? For how long?

(Peptic ulcer disease has risk factors that include frequent (Peptic ulcer disease has risk factors that include frequent use of nonsteroid antiinflammatory drugs (NSAIDs), alcohol, use of nonsteroid antiinflammatory drugs (NSAIDs), alcohol, smoking, and HP infection)smoking, and HP infection)

Examiner asks (Rationale)Nutritional assessmentNutritional assessment

•Now I would like to ask you about your diet. Please tell me Now I would like to ask you about your diet. Please tell me all the food you ate yesterday, starting with breakfastall the food you ate yesterday, starting with breakfast

Objective data:1. Inspection (symmetry,

umbilicus, skin, pulsation or movement, hair distribution, demeanor)

2. Auscultation (bowel & vascular sounds)

3. Percussion (general tympany, liver span & splenic dullness)

4. Palpation (superficial & deep)

Preparation•The lighting should include a strong overhead light and a The lighting should include a strong overhead light and a secondary stand light. Expose the abdomen so that is fully secondary stand light. Expose the abdomen so that is fully visible. Drape the genitalia and female breasts.visible. Drape the genitalia and female breasts.

•The person should have emptied the bladderThe person should have emptied the bladder

•Keep the room warm to avoid chilling and tensing of Keep the room warm to avoid chilling and tensing of musclesmuscles

•Position the person supine, with the head on the pillow, the Position the person supine, with the head on the pillow, the knees bent or on pillow, and the arms at the sides or acroos knees bent or on pillow, and the arms at the sides or acroos the chestthe chest

•The stethoscope endpiece must be warm, your hands must The stethoscope endpiece must be warm, your hands must be warm, and your fingernails must be very shortbe warm, and your fingernails must be very short

•Inquire about any painful areas. Examine such an area last Inquire about any painful areas. Examine such an area last to avoid any muscle guardingto avoid any muscle guarding

•Enhance muscle relaxation through breathing exercises; Enhance muscle relaxation through breathing exercises; emotive imagery; your low, soothing voice; and the person emotive imagery; your low, soothing voice; and the person relating his or her abdominal history while you palpaterelating his or her abdominal history while you palpate

Inspect the abdomen

ContourContour– Stand on the person’s right side and look down on the Stand on the person’s right side and look down on the

abdomen. Then stoop or sit to gaze across the abdomen. abdomen. Then stoop or sit to gaze across the abdomen. Determine the profile from the rib margin to the pubic Determine the profile from the rib margin to the pubic bone. Normally the contours are the flat or rounded.bone. Normally the contours are the flat or rounded.

Inspect the abdomen

SymmetrySymmetry– Shine a light across the abdomen toward you, or lengthwise Shine a light across the abdomen toward you, or lengthwise

across the person. The abdomen should be symmetric across the person. The abdomen should be symmetric bilaterally. Note any localized bulging, visible mass, or bilaterally. Note any localized bulging, visible mass, or asymmetric shape. Step to the foot of the examination table to asymmetric shape. Step to the foot of the examination table to recheck the symmetry.recheck the symmetry.

– Ask the person to take a deep breathe to further highlight any Ask the person to take a deep breathe to further highlight any change. Or ask the person to perform a sit up without pushing change. Or ask the person to perform a sit up without pushing up with his or her hands.up with his or her hands.

UmbilicusUmbilicus– Normally it is midline and inverted, with no sign of Normally it is midline and inverted, with no sign of

discoloration, inflammation or hernia.discoloration, inflammation or hernia.

Inspect the abdomen

SkinSkin– The surface is smooth, with The surface is smooth, with

homogeneous color.homogeneous color.– One common pigment change is One common pigment change is

striae. They occur when elastic striae. They occur when elastic fibers in the reticular layer of the fibers in the reticular layer of the skin are broken following rapid or skin are broken following rapid or prolonged stretching (pregnancy, prolonged stretching (pregnancy, excessive weight gain). excessive weight gain).

– If a scar is present, draw its location If a scar is present, draw its location in the persons record, indicating the in the persons record, indicating the length in cm.length in cm.

– Veins usually are not seenVeins usually are not seen– Skin turgor. Gently pinch up a fold of Skin turgor. Gently pinch up a fold of

skin, then release (skin immediately skin, then release (skin immediately returns to original position)returns to original position)

Inspect the abdomen

Pulsation or movement (aorta, respiratory Pulsation or movement (aorta, respiratory movements, waves of peristalsis)movements, waves of peristalsis)

Hair distributionHair distribution

Auscultate bowel & vascular sounds Bowel soundsBowel sounds

– Begin auscultation from the Begin auscultation from the RLQ.RLQ.

– Note the character and Note the character and frequency.frequency.

– Bowel sounds are high Bowel sounds are high pitched, cascading, pitched, cascading, occurring from 5 to 30 occurring from 5 to 30 times per minute.times per minute.

Vascular soundsVascular sounds– Check over the aorta, renal Check over the aorta, renal

arteries, illiac and femoral arteries, illiac and femoral arteriesarteries

Percussion

General tympanyGeneral tympany– Percuss lightly in all four quadrants to determine the prevailing Percuss lightly in all four quadrants to determine the prevailing

amount of tympany or dullness. Tympany should predominate amount of tympany or dullness. Tympany should predominate because air in intestines rises to the surface when the person because air in intestines rises to the surface when the person is supineis supine

Percussion Liver spanLiver span

– Measure in the right medclavicular line.Measure in the right medclavicular line.– Begin in the area of the lung resonance and percuss down the Begin in the area of the lung resonance and percuss down the

interspaces untill the sound changes to a dull quality. Mark the interspaces untill the sound changes to a dull quality. Mark the spot (N - V intercostal space)spot (N - V intercostal space)

– Find abdominal tympany and percuss up. Mark where the Find abdominal tympany and percuss up. Mark where the tympany changes to the dullness (N – right costal margin)tympany changes to the dullness (N – right costal margin)

– Measure the distance between to marks. (N – 6-12 cm; m – Measure the distance between to marks. (N – 6-12 cm; m – 10,5 cm; f – 7 cm)10,5 cm; f – 7 cm)

Percussion Splenic dullnessSplenic dullness

– You may locate it by percussing for a dull note from the 9You may locate it by percussing for a dull note from the 9thth to to 1111thth intercostal space just behind the left midaxillary line intercostal space just behind the left midaxillary line

– Normally is not wider than 7 cmNormally is not wider than 7 cm– Percuss in the lowest interspace in the left anterior axillary linePercuss in the lowest interspace in the left anterior axillary line

Percussion Costovertebral angle tendernessCostovertebral angle tenderness

Palpation Light palpationLight palpation

– With the first 4 fingers close together, depress the skin about 1 cmWith the first 4 fingers close together, depress the skin about 1 cm– Make a gentle rotary motion, sliding the skin and fingers together. Make a gentle rotary motion, sliding the skin and fingers together.

Than lift the fingers and move to the next location (muscle guarding Than lift the fingers and move to the next location (muscle guarding (voluntary or involuntary), rigidity, large masses, tenderness)(voluntary or involuntary), rigidity, large masses, tenderness)

Palpation Deep palpationDeep palpation

– Push down about 5 to 8 cmPush down about 5 to 8 cm– To overcome the resistance of a very large or obese abdomen, To overcome the resistance of a very large or obese abdomen,

use a bimanual techniqueuse a bimanual technique

Palpation LiverLiver

– Place your left hand under the persons back parallel to the 11Place your left hand under the persons back parallel to the 11thth and 12and 12thth ribs and lift up to support abdominal contents ribs and lift up to support abdominal contents

– Place your right hand in RUQ, with fingers parallel to the midlinePlace your right hand in RUQ, with fingers parallel to the midline– Push deeply down and under the right costal marginPush deeply down and under the right costal margin– Ask the person to take a deep breatheAsk the person to take a deep breathe– Try to feel the liver edge bump your fingertipsTry to feel the liver edge bump your fingertips

Palpation SpleenSpleen

– Normally the spleen is not palpableNormally the spleen is not palpable– Reach your left hand over the abdomen and behind the left side Reach your left hand over the abdomen and behind the left side

at the 11at the 11thth and 12 and 12thth ribs. Lift up for support ribs. Lift up for support– Place your right hand on the LUQ with the fingers pointing Place your right hand on the LUQ with the fingers pointing

toward the left axilla and just inferior to the rib margintoward the left axilla and just inferior to the rib margin– Push your hand deeply down and under the left costal margin Push your hand deeply down and under the left costal margin

and ask the person to take a deep breathe. You should feel and ask the person to take a deep breathe. You should feel nothing firmnothing firm

Palpation KidneysKidneys

– Search for the right kidney by placing your hands in a “duck-Search for the right kidney by placing your hands in a “duck-bill” position at the person’s right flankbill” position at the person’s right flank

– Press your two hands together firmly and ask the person to Press your two hands together firmly and ask the person to take a deep breathetake a deep breathe

– In most people you will fell no change. Occasionally, you may In most people you will fell no change. Occasionally, you may feel the lower pole of the right kidney as a round, smooth mass feel the lower pole of the right kidney as a round, smooth mass slide between you fingersslide between you fingers

Palpation KidneysKidneys

– The left kidney is not palpable normallyThe left kidney is not palpable normally– Search it by reaching your left hand across the abdomen and Search it by reaching your left hand across the abdomen and

behind the left flank to supportbehind the left flank to support– Push you right hand deep into the abdomen and ask the Push you right hand deep into the abdomen and ask the

person to breathe deeplyperson to breathe deeply– You should feel no changeYou should feel no change

Palpation AortaAorta

– Using your opposing thumb and fingers, palpate the aortic Using your opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of midlinepulsation in the upper abdomen slightly to the left of midline

– Normally it is 2,5 to 4 cm wide and pulsates in the anterior Normally it is 2,5 to 4 cm wide and pulsates in the anterior directiondirection

Palpation Special proceduresSpecial procedures

– Rebound tenderness (Blumberg’s sign). Choose a site away Rebound tenderness (Blumberg’s sign). Choose a site away from the painful area. Hold your hand 90 degrees to the from the painful area. Hold your hand 90 degrees to the abdomen. Push down slow and deeply; than lift up quickly. The abdomen. Push down slow and deeply; than lift up quickly. The normal (negative) response – no pain on release or pressure.normal (negative) response – no pain on release or pressure.

Palpation Special proceduresSpecial procedures

– Inspiratory arrest (Murphy’s sign). Hold your fingers Inspiratory arrest (Murphy’s sign). Hold your fingers under the liver border. Ask the person to take a deep under the liver border. Ask the person to take a deep breathe.breathe.

THANK YOU FOR YOUR THANK YOU FOR YOUR ATTENTION!ATTENTION!