HISTORY &

PHYSICAL
EXAMINATION
DR. BURDADOR
 ABDOMINAL EXAMINATION

HOW TO MAKE A GREAT HISTORY Pain:

- Check referral forms - Severity (scale of 1 to 10)
o Abdominal pain r/o appendicitis - OPQRST
o Bowel obstruction for 5 days o Onset
- What questions do I needed to be answered? o Previous episodes
- Surgical history is a focused history o Position
o Palliating factors
General Considerations: o Progression
1. Good lightning: o Quality of pain
o Look for abdominal movement o Radiation
o Observe color of skin o Relieving factors
2. Empty bladder: o Severity and timing
o So not to mistake abdominal content as mass - Main things to ask:
o May void when examined o What is the pain like?
3. Proper draping o How severe is it?
o Covered from breast above o What precipitated the pain?
o Covered from pubic symphysis down o What aggravates the pain?
4. Warm hands, short nails o What relieves the pain?
o Cold hands may contract abdomen, may be - Appendicitis:
mistaken for rigidity or muscle spasm o Crampy pain around the belly button and moves
5. Long nails may cause pain during palpation and to the right side and gets sharper as it advances
percussion (mistaken as tenderness) - Biliary colic:
6. Monitor Facial Expression o Pain in the righthand side of the upper part of my
o Note the severity of pain tummy after I eat and tends to come and go and
7. Palpate the area of pain last sometimes go to my shoulder as well as
o If palpated first, spasm may not allow you to sometimes
palpate other areas
8. Relaxation of the Abdomen Previous Surgical History
o Put in proper position - Yo e in he ge e ice
o Build rapport for reassurance o What operation it was and what was it for
9. Companion for opposite sex patients - Abdominal pain but appendectomy in the past
o Makes appendicitis much less likely
Introduction: - Post-surgical complication
- Introduce yourself o Check operation note
- Reason for consult - Do not be afraid to look into previous admissions
- Establish a timeline
o When was the patient well Medical History:
o When was the patient unwell - Keep it simple
o How things developed from then until now - Think of big things you need to know for surgery:
- Consider the history as story telling o Previous hospitalizations
o Cardiac? Pulmonary? Diabetic?
Presenting Symptoms: o Asthmatic? Epileptic?
- Know the main symptoms of complaint - Medication
- Sometimes, there is more than one symptom o Full list of medication
o Appendicitis (Abdominal pain from Epigastric to o Match medication with illness in medical history
RUQ) o Wa ch o fo medica ion ha don ma ch
o Bowel Obstruction (Vomiting) - Allergy
- Established how long have they been sick (is there o I he e an medica ion e can gi e?
progression) o Ho did he kno he e alle gic?
- What happened to the symptoms over time o What sort of reaction did they have?
- How the main symptom affected them
- Basic functions of life Family History:
o Are you eating okay? - Ch on Di ea e
o Are you sleeping okay? o Family history of inflammatory bowel disease?
o Are you going around the house? - Bowel Obstruction
o Are you going to work? o Family history of colon cancer?

Associated Symptoms: Sexual History:

- Types of symptoms that go together - Pregnant? Ectopic pregnancy?
o Pain, vomiting, nausea - Recreational drug use
o Abdominal distention, constipation, obstipation
o Constitutional symptoms, weight loss, energy,
appetite, night sweats
- Other symptoms aside from the main one
- Pattern of symptoms (this piece of history sounds like this
diagnosis)
- Make a theory and test it through taking a proper history
PHYSICAL EXAMINATION Auscultation:
- Putting pieces together - Can listen to anywhere in the abdomen
- Established: - Bowel sounds:
o Main and associated symptoms o Normal gurgling (5-20 waves/minute)
o Pa ien medical hi o Right iliac fossa is the loudest due to
o Medications and Allergies ileocecal valve
- Purpose of PE: 30-60 seconds absent of bowel sounds
o Evidence from patient to support one theory over o Abnormal inkling (ob c ion)
another o Absent ileus/peritonitis
o To ge an idea of ha ha ening o he a ien - Bruits:
before blood work-ups and X-rays o Aortic bruits above the umbilicus (AAA)
o To confirm diagnosis from history o Renal bruits above the umbilicus, slightly
- Rapport lateral to the midline (Renal artery stenosis)
o Far more invasive than history taking
o Be gentle with patients Percussion: assess the amount and distribution of gas
o P e e e a ien digni (co e and be done o Tympany due to gas in GI
as quickly as we can) o Dullness underlying mass or organ
Introduction: - Vibration will irritate the inflamed organ causing
- Wash hands and introduce yourself tenderness, thus supplement palpation in tenderness
- Confirm patient details (name and DOB) examination
- Explain the procedure - Detects fluid shift and air in the abdomen
- Gain consent o Supine patient resonant midline, dull flanks
- Position the patient: o Lateral patient dullness beyond umbilicus,
o Make patient comfortable in supine position with slightly shifting dullness
flexed knees slide hand under the low back to see if - Confirm findings and positions of abdominal organs
patient is relaxed on bed o Liver enlarged if dullness goes beyond
o Ask patient to keep the arms at the side or folded across subcostal margins from the chest
the chest (not above the head) Lower border:
o Drape the patient: cover at the level of symphysis pubis Percuss from RLQ
and expose abdomen just above the xiphoid process below umbilicus
- Ask the patient to point areas of pain so you can examine upward to the liver
it last
- Warm your hands and stethoscope. Approach the patient Upper border:
calmly and avoid quick unexpected movements From nipple line
downward in the MCL
Inspection: until resonance shifts
- Look around bedside for treatments or adjuncts (feeding to liver dullness
tubes, stoma bags, drain)
- General appearance lying with discomfort, pain, o Spleen - enlarged if dullness goes beyond
agitation, confusion subcostal margins from the chest
- Body habitus obese, low BMI, cachectic Percuss the left
- Abdominal contour: Flat, Scaphoid or Distended? lower anterior chest
- Skin inspection: wall Traube space:
o Temperature
o Color jaundice, anemia from 6th rub to the
o Scars describe their location anterior axillary line
Midline laparotomy down to costal margin
RIF appendectomy for splenomegaly
Right Subcostal Cholecystectomy
Groin Hernial repair o Bladder percuss the dullness and height
o Masses? Assess: above the symphysis pubis at the suprapubic
Size, Position, Mobility, Consistency region
o Swelling? Hernia? Suprapubic masses (bladder) dull
o Striae? Rashes? Echhymoses? Bowel resonant
Silver striae normal old pregnancy Palpation:
Purplish striae new pregnancy - Ask about any areas of pain and examine these last
o Pulsation - Ob e e he a ien face h o gho fo ign of
discomfort
Retroperitoneal bleeding: (Pancreatitis/Ruptured AAA) - Divide abdomen into:
1. C llen Sign bruising surrounding umbilicus o 9 regions and 4 quadrants
2. Grey- ne ign bruising in the flanks
Light Palpation (1cm deep) - Kidney Palpation
- Palpate each 9 abdominal regions assessing: o Left hand behind a ien back a igh flank
o Direct Tenderness note the area and severity o Right hand just below the right costal margin in
of pain the right flank
o Rebound tenderness worse on releasing o Pe he igh hand finge dee in o he
(peritonitis) abdomen
o Ro ing Sign contralateral tenderness o At the same time press upwards with your left
o Guarding involuntary tension hand
o Masses superficial enlargement of organs o Ask patient to take a deep breath
o Feel the lower pole of kidney moving inferiorly
Deep Palpation o Repeat process on the opposite side
- Assess 9 regions and 4 quadrants again with greater
pressure to assess:
o Masses:
Location
Size
Shape
Consistency
Tenderness
Pulsations
- Liver Palpation
o Begin at right iliac fossa using flat edge of your
hand
o Press your hand into the abdomen as you ask
the patient to take a deep breath
o Feel a step, as the liver edge passes below your
hand and assess: - Gallbladder
Degree of extension below the costal o Not usually palpable
margin (3cm) o Enlarged: Obstruction
Consistency of liver edge o Rounded mass moving with respiration noting
Tenderness (hepatitis) tenderness
Pulsations: tricuspid regurgitation Palpation at right costal margin, MCL
o If o don feel an hing, e ea oce 1-2cm 9th rib tip
higher o M h ign
Pain upon inspiration while palpation
If no discomfort on the other side,
suggestive of cholecystitis

- Aorta
o Palpate using fingers of both hands
o Press firmly just above the umbilicus at the borer
of aortic pulsations
o Note the movement of your fingers
Upward: Pulsatile
Downward: Expansile (AAA)

- Spleen Palpation
o Only palpable when enlarged 3 times than
normal size
o RIF aligning your fingers in the same direction as
left costal margin
o Press right hand into the abdomen and ask
patient to take a deep breath
o Feel of the splenic notch passing under your
hand
o If o don feel an hing, e ea oce 1-2cm
closer to left hypochondriac
 M H. A M C M
C I I
( CI I)

MODULE ON ABDOMINAL EXAMINATION

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 M H. A M C M
C I I
( CI I)

PERFORMANCE RA ING CALE

ABDOMINAL EXAMINATION
( IM LA ED OR AC AL PA IEN )

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