1 Abdominal Exam (Advanced)

conuyaro's version from 2015-11-28 11:44

Anatomy Review

Question Answer
liver under ribs7-11
gallbladder locatR of rectus abdominus, below costal margin
pancreas locatretroperit, behind stomach
stomach locatLUQ
spleen under ribs9, 10, 11 on L
kidneys behind ribs11 and 12
colon in RLQcecum and appendix
colon in LLQsigmoid (retroper)

Inspection of Abdominal Wall

Question Answer
scaphoid abdomensunken, seen in cachectic patients
Cupid's bowacute pancreatitis (umbilicus like dimple)
Auenbrugger's signbulge in epigastrium, large pericardial effusion
bulge in hypogastric areadistended bladder
bulge over upper quadrantsH-S-megaly
"ladder" pattern of distentionsmall bowel obstruction
inverted "U" pattern of distentionlarge bowel obstruction
Grey Turner's signbilat flank bruise, acute hemorrhagic pancreatitis
purple striae / stretch markCushing's

Inspection of Umbilicus

Question Answer
eversionintra-abdom pressure (ascites)
Sister Joseph's nodulemetastatic involvement by intra-abdom malig (stomach, ovary, colon, pancreas, rectum)
Cullen's signintraperitoneal bleed (bruise), acute hemorrhagic pancreatitis
downward displacementascites, HS-megaly
upward displacementpreg, pelvic tumor


Question Answer
abdominal paradoxrocking of chest and ab due to paralysis or weakening of diaphragm, predicts respir failure, precedes deterioration of arterial blood gases
respiratory alternansalternate use of either diaphragm or intercostals, predicts respir failure
still abdomenperitonitis (diffuse in generalized, localized in focal--appendicitis, diverticulitis)

Abnormal Venous Patterns

Question Answer
obstruction of SVC characterized byengorged vv on upper ab wall, downward flow venous on harvey test
obstruction of IVC characterized byengorged vv on lat ab wall, upward flow venous on harvey test
obstruction of portal sys characterized byperiumbilical vv (caput medusae), rostral drain up, caudal drain down , away from umbilicus venous flow on harvey test


Question Answer
AAAdiameter of expansile mass 3 cm or more (very specific, not very sensitive for if under 5 cm) , pulsatile mass


Question Answer
bowel sounds incr in intestinal obstruction b/ctone of loop is incr
prev of incr bowel sounds in obstruction50% (25% may have diminished sounds)
abdom murmurs systolic or diastolic?systolic
bruits systolic or diastolic?contin
prev of murmurs/bruits in normals20%, declines w/ age
systolic murmur of epigastriumnormal, preg (comes from celiac tripod)
RUQ murmur/bruithepatic tumor, metastatic liver disease, cirrhosis, vessel malformation, tricuspid regurg
LUQ murmur/bruitpancreatic cancer, vascular anomaly of spleen
renal vascular disease producecontin murmur in upper quads
Cruveilhier-Baumgarten murmurvenous hum (recanalization of umbilical v in portal HTN), louder in Valsalva, often w/ thrill
Cruveilhier-Baumgarten diseasecongenital patency of umbilical v, liver small and atrophic
Cruveilhier-Baumgarten syndromeportal HTN, acquired reopening of umbilical v
friction rub over R or LUQinfarcts or tumors of liver/spleen
succussion splashcaused by shaking patient, not sensitive or specific (GOO, hydropneumothorax, intestinal obstruction, gastric dilatation)


Question Answer
tenderness indicatesdistention of capsule (passive congestion), inflamm
firm, hard edgetumor
sharpe edgecirrhosis
nodulescancer or cirrhosis
pulsatile edgeconstrictive pericarditis, tricuspid regurg (inspiratory incr in magnitude of pulse means TR)
Rivera-Carvallo maneuverinspiratory incr in TR murmur on hepatojugular reflex test


Question Answer
normal liver span by light percussion<12-13 cm on MCL
estimation of liver size via indirect percussionunderestimate
friction rubs heard inhepatomas and 10% of metastatic tumors
bruitsneoplasms (esp if also a rub), hepatitis
venous humsportal HTN


Question Answer
Murphy's signarrest of inspiration trigger by palpating inflamed fundus gallbladder at 9th costal cartilage (press the line that join costal margin and lateral border of rectus abdominis), cholecystitis
sonographic Murphy's signpain when use ultrasound to locate gallbladder for palpation
cholecystitis findingspos Murphy's, hypersens over R costophren angle (Boas' sign), rub, rarely have tender palpable mass
Courvoisier's lawin painless jaundice, a palpable non-tender gallbladder is due to cancer of biliary tract or pncreatic head, not cholelithiasis (stones)
gold standard for biliary stonesultrasound


Question Answer
ballottementlift up L hemithorax with L hand while feeling w/ R for impulse transmitted by large spleen
scale for splenomeg0=nonpalp, 1=only palp on deep inspir, 2=btwn L costal margin and halfway to umbilicus, 3=to umbilical line, 4=halfway btwn umbilicus and symphysis, 5=beyond umbilical line
splenomeg w/ concomitant hepatomegprimary liver disease w/ spleen enlargement due to portal HTN
splenomeg + lymphadenopathyhematologic or lymphoproliferative disease
massive splenomegmyeloprolif etiology
Kehr's signreferred left shoulder pain due to splenic injury eg rupture, abscess ( can occur without elicit it or can elicit it by deep palpation on LUQ with patient in Trendelenburg position)
gold standard for splenomegultrasonography

Percussion and Auscultation of Spleen

Question Answer
Nixon's techniquepercus of entire outline in R lat decub
Castell's techniqueprecus of lowest L intercostal along ant axillary line during inspir and expir, should be resonant (dull note on inspir indicates enlargement)
precussion of Traube's semilunar spacedullness w/in L 6th rib, L midax line, and L costal margin indicates enlargement
rubindicates splenic infarct
murmurindicates massive splenomeg, carcinoma of pancreas compressing splenic a


Question Answer
clapotagesplashing sound produced by mvt of fluid in stomach (tap epigastrium)
succussion splashindicates delay in gastric emptying if 5 hrs after meal, GOO


Question Answer
pancreatitis sometimes assoc w/Cullen's sign, Grey Turner's sign, Cupid's bow profile,Mallet-Guy's sign, pseudocyst)
Mallet-Guy's sign tenderness to percus of thoracolumbar spine
most common sequelapseudocyst (visible deformation of abdom wall)


Question Answer
assess size viaultrasound
ant systolic murmurrenovascular disease (50%), heard in horizontal band across umbilicus, high false-pos rate
post systolic murmurbtwn lumbar col and costal margins, high specif, low sensitivity for renovascular disease
ant contin bruitgood sensitivity for renovascular disease (higher in HTN w. fibromuscular hyperplasia of renal a)

Urinary Bladder

Question Answer
subjective palpationpress w/ 1 finger stepwise until patient feels urge to urinate
subjective palpation can detect distention of200 mL

The Acute Abdomen (Peritoneal Exam)

Question Answer
most commonly used maneuversguarding/rigidity, ab wall tenderness, rebound tenderness
guardingdiffuse or localized tension of ab wall (invol or voluntary)
invol guardingrigidity
localized rigidityfocal area of peritonitis (often absence of respir motion)
induced guardinghave patient raise head and touch chin to chest while palpating to elic Carnett's sign
Carnett's signto know pain originate from intraabdominal or abdominal wall origin. first localize the site of tenderness by palpate. then contract abdominal muscle by asking patient to flex their hip or flex their neck. then palpate again. if same or more tenderness then it is positive which indicate pain from abdominal wall.
ab wall tenderness (modified induced guarding)same as induced guarding, but patient sits up halfway w/ arms crossed
cause of positive ab wall tenderness (AWT)diabetic neuropathy of lower thoracic segs (assoc w/ hyperesthesia and weakness of wall), mm strain, viral myositis, fibrositis, nerve entrapment, trauma
AWT maneuver warningsnot effective in children or elderly, inhumane for patients who already have rigidity, dangerous if intra-ab abscess present


Question Answer
rebound tenderness (Blumberg's sign)severe pain of ab wall indirectly elicited by sudden release of hand pressure (inflamed peritoneum suddenly tensed)
referred rebound tenderness testdo test on contralat quad
cough testsudden incr in ab pain during coughing (peritonitis)
jar tendernesspatient stands on toes and then drops onto heels
Valsalvamay heighten peritoneal pain so patient can localize it more precisely (good screening test for appendicitis)
stethoscope signsay you're only listening and palpate w/ stethoscope--seems to distract so that patients respond w/ less pain to deep palpation=separate real pain from exaggerated/fabricated pain
closed-eyes signpatients w/ nonspecific ab pain tend to close their eyes during palpation rather than watch, indicating there isn't a true pathology
hyperesthesiahypersensitivity to light touch over inflamed viscus ("Head's zones"), seen in herpes zoster, PUD, and Boas' sign over R costophrenic angle due to inflamed gallbladder

Maneuver's for Evaluation of Suspected Appendicitis

Question Answer
most commonMcBurney's sign, Rovsing's sign, obturator test, reverse psoas maneuver, rectal tenderness
McBurney's signpain/rigidity of McBurney's pt (1.5-2 in med to R antero-sup iliac spine on line line joining it to umbilicus)
Rovsing's signpain in R iliac fossa caused by pressure over LLQ
obturator testflex hip and rotate internally causes suprapubic pain for R leg (may be both bo OB-GYN prob) - pelvic appendix
Psoas signpain when hyperextend R hip - retrocecal appendix
rectal tendernessusually only helpful in case of perforation (pelvic abscess creates mass)

Ascites (Dropsy)

Question Answer
due to 1 of 3 probsincr hydrostatic pressure (R-sided or biventric failure), decr oncotic pressure (malnutrition or protein loss--cirrhosis, nephrosis, enteropathy), or peritoneal inflam (neoplastic or infectious)
history must ask abouthistory of liver disease and recent weight gain (esp incr abdom girth and ankle edema)
ankle edema caused by ascites due tocompression of leg vv by fluid and hypoalbuminemia (seen in hepatic and renal disease)
classic maneuversinspection for bulging flanks, percus for flank dullness, shifting-dullness maneuver, fluid-wave test
bulging flanksflanks pushed outward when supine (may also be due to obesity)
flank dullness testprecuss outward from umbilicus toward flanks and symphysis (typany around umbilicus from bowel loops, dullness on flanks, separated by horizontal border)
shifting-dullness maneuverpercuss down along flank from umbilicus and mark where turns resonant to dull, repeat w/ patient on side, gravity-dependent shift in dullness of at least 1 cm means at least 500-1000 ml fluid present
fluid-wave maneuver1 examiner presses hand on 1 flank and taps other, other examiner (or patient) placed ulnar sides of hands on umbilicus to prevent false-pos from test producing wave of mesenteric fat, pos if examiner feels fluid wave from contralat side (must be moderate-to-strong)
only truly specific bedside test for ascitesfluid-wave


Question Answer
puddle signlie on belly for 5 minutes, then on hands and knees, stethoscope over most dependent part of abdomen and flick over flank, gradually move stethoscope to opposite flank, pos if sound suddenly incrs in intensity and clarity as stethoscope moves past area of fluid, poor sensitivity
Guarino's variation of auscultatory percussionsit or stand 3 for 3 minutes after voiding, stethoscope in abdom midline right above pubic crest while percussing ab from costal margin toward pelvis along 3 or more vertical lines, pos if dull-to-loud change occurs above pelvic border
ballottement sign (dipping maneuver)tilt toward side of organ to be palpated, quickly push organ, pos sign if patient feels displaced fluid before the examiner can touch the organ


Question Answer
most useful signs to rule in ascitespos fluid-wave, history of ankle edema
least useful signs to rule in ascitespuddle sign, auscultatory percussion
most useful signs to rule out ascitesabsence of ankle edema, absence of flank dullness
bedside maneuvers can detect ? amt of fluid500-1000 ml
ultrasound can detect ? amt of fluid100 ml
predictive value of tests enhanced byprothrombin time (ascites more likely if PT is prolonged)