ABDOMINAL PE

.
 REGIONS
OF THE
ABDOMEN
 RIGHT UPPER QUADRANT

• Liver, gall bladder, pylorus, duodenum, head of pancreas,

ascending colon, right kidney, adrenals

RIGT LOWER QUADRANT

REGIONS • Right kidney, ureter, cecum, appendix, ascending colon,

ovary, fallopian tube, spermatic cord, uterus/bladder (if

OF THE
enlarged)

LEFT UPPER QUADRANT

ABDOMEN • Liver (left lobe), spleen, stomach, body of pancreas,
descending colon, left kidney

LEFT LOWER QUADRANT

• Left kidney and ureter, sigmoid and descending colon, ovary

and fallopian tube, spermatic cord, uterus/bladder (if
enlarged)
 INSPECTION
PHYSICAL
EXAMINATI AUSCULTATIO
ON OF THE
ABDOMEN
N
PERCUSSION
PALPATION
 INSPECT THE SURFACE,
INSPECTION CONTOURS, AND MOVEMENTS
OF THE ABDOMEN
INSPECTION ■ COUNTOUR
– Flat
: – Rounded
– Scaphoid
– Protuberant
■ Fat
■ Gas
■ Pregnancy
■ Ascites
■ Intraabdominal mass
or hernia
■ tumor
INSPECTION ■ scars
:
■ Striae
– Old silver striae or stretch marks are normal.
SKIN – Pink–purple striae indicate Cushing’s syndrome.
INSPECTION ■ dilated veins
– Scarcely visible
: – A few small veins may be visible normally
– Clinical occurrence
Dilated veins can be indicative of hepatic

SKIN cirrhosis or of inferior vena cava obstruction.

INSPECTION ■ Caput medusae
– Dilated subcutaneous veins
: – Severe portal hypertension due to liver cirrhosis
– Massive ascites and umbilicus not seen

SKIN ■ Spider angiomas

– Dilated arteriole
INSPECTION
INSPECTION ■ Peristalsis
– Slow undulations under skin
– Examiner sits at the right side of the patient,
head slightly higher than the abdomen
– Seen in thin abdominal wall
– Clinical occurrence
■ Pyloric obstruction
■ Small and large intestine obstruction
■ Thin persons
 ■ Umbilicus
– Everted
INSPECTION ■ Without hernia, it is a sign of increase intraabdominal
pressure
l
■ Tumor, ascites, pregnancy
– Umbilical fistula
■ (+/-) abnormal discharge
■ Urine – patent urachus
■ Pus – urachal cyst or intraabdominal abscess
■ Feces – connection from the colon
– Umbilical calculus
■ Hard mass of dirt
– Nodular umbilicus (Sis Mary Joseph)
■ Abdominal carcinoma especially gastric carcinoma with
metastasis to the navel
– Bluish umbilicus (Cullen’s sign)
■ Bluish discoloration of the navel due to retroperitoneal
hemorrhage
INSPECTION ■ Ecchymoses on abdominal and flanks
– Discoloration due to ecchymoses in lower
: abdomen and flanks
– Due to infiltration of extraperitoneal tissue with
SKIN blood from retroperitoneal bleeding
– Clinical occurrence
■ Hemorrhagic pancreatitis
■ Strangulated bowels
■ Hemorrhages from abscesses
■ Trauma
■ Ectopic pregnancy
INSPECTION ■ Observe its contour and location and any
inflammation or bulges suggesting a ventral hernia.

:
AMBILICUS ■ Abdominal hernia
– Protrusion due to weak point in abdominal wall
– Reducible
■ Contents in the sac can be pushed back
– Irreducible/incarcerated
■ Cannot be pushed back
– Strangulated
■ Bowels are firm but not tender
 ■ LISTEN TO THE ABDOMEN
BEFORE PERFORMING

AUSCULTATION PERCUSSION AND PALPATION

BECAUSE THESE MANEUVERS
MAY ALTER THE FREQUENCY
OF BOWEL SOUNDS
 ■ BRUIT
– If the patient has high blood pressure,
AUSCULTATI listen in the epigastrium and in each
upper quadrant for bruits. Later in the
ON examination, when the patient sits up,
listen also in the costovertebral angles.
Epigastric bruits confined to systole are
normal.
AUSCULTATION

■ RUBS
– Rubs over the liver are most likely neoplastic, but may occur in
inflammatory disease, including acute cholecystitis
– Splenic infarcts can generate LUQ rubs
AUSCULTATION
■ BOWEL SOUNDS
– Hyperactive: diarrhea or early intestinal obstruction
– Hypoactive to absent, as in adynamic ileus and peritonitis
– Highly-pitched tinkling sound suggest intestinal fluid and air under
tension in a dilated bowel.
– Rushes of high-pitched sound coinciding with an abdominal cramp
indicates intestinal obstruction
■ BORBORYGMI
– Prolonged gurgles of hyperperistalsis
PERCUSSION

■ HELPS ASSESS THE AMOUNT AND

DISTRIBUTION OF GAS IN THE ABDOMEN,
POSSIBLE MASSES THAT ARE SOLID OR FLUID-
FILLED , AND THE SIZE OF LIVER AND SPLEEN.
 ■ TYMPANY
– Predominant percussion tone
PERCUSSION – Due to gas in the abdomen
■ DULLNESS
– Scattered all over the abdomen
– Signifies presence of underlying mass,
organ fluid and/or feces.
 ■ Tympanitic in anterior but dull in flank areas
PERCUSSIO – ascites
N OF THE ■ Dullness in both flanks prompts further
assessment for ascites
ABDOMEN: ■ Increasing dullness in left plank – splenic
SOUND AND rupture or hemorrhage or splenomegaly

INDICATION
PERCUSSION: ■ Liver span
– Below level of umbilicus, RMCL
LIVER - Mark the site of dullness
– Upper border of the liver is percussed in the
right midclavicular line starting at the
midchest
– Resonance becomes dull as upper border of
the liver is reached and becomes resonant
again as lower level of the liver is reached
– Total span shouldn’t exceed 10cm
■ Size and shape can be estimated by percussion
PERCUSSION ■ Decrease liver size
– Liver cirrhosis
: ■ Alcoholic liver disease
LIVER ■ Non-alcoholic fatty liver disease
(NAFLD)
■ Viral hepatitis
■ Hemochromatosis
– Perforation of hollow viscus or gas in colon
■ Free air below the diaphragm may
decrease the area of the dullness
■ Gas in colon at RUQ may obscure liver
dullness
PERCUSSION: ■ Increase liver dullness
– Hepatomegaly
LIVER – Alcoholic liver disease
– NAFLD
– Chronic passive congestion
– Hepatocellular carcinoma
– Hepatic abscess

■ Tenderness in the liver

– Suggest inflammation and congestion
 ■ Normal spleen weighs 150g and approximately 11cm
in caraniocaudal length.
■ 400-500g – indicates splenomegaly
PERCUSSION: ■ Causes of splenomegaly
SPLEEN – Immune response
■ Subacute bacterial endocarditis
■ Infectious mononucleosis
– RBC destruction
– Myeloproliferative
■ Chronic myeloid metaplasia
– Infiltrative
■ Sarcoidosis
■ Neoplasms
– CLL
– Lymphoma
PERCUSSION: ■ Percuss the left lower anterior chest wall
roughly from the border of cardiac dullness
SPLEEN at the 6th rib to the anterior axillary line and
down to the costal margin, an area termed
Traube’s space.
■ Check for a splenic percussion sign. Percuss
the lowest interspace in the left anterior
axillary line. This area is usually tympanitic.
■ Ask the patient to take a deep breath, and
percuss again.
■ When spleen size is normal, the percussion
note usually remains tympanitic.
PERCUSSION ■ Place the ball of one hand in the
costovertebral angle and strike it with the
KIDNEY ulnar surface of your fist.
■ Use enough force to cause a perceptible but
painless jar or thud.
■ Pain with pressure or fist percussion suggests
pyelonephritis but may also have a
musculoskeletal cause.
 ■ Shifting dullness
– Fluid-intense interface shifts up towards
PERCUSSIO umbilicus when patient is turned on the side
N: ■ Fluid wave
– Healthy men have little or no intraperitoneal
TO DETECT fluid. Women may normally have as much as
ASCITES 20mL, depending on the phase of menstrual
cycle.
– Portal hypertension and hypoalbuminemia
■ Puddle sign: Knee Chest
– Flicking sound increased as the chest piece
moves away from the examiner
– (+) even 120mL
PERCUSSION: ■ Dull
– Filled with fluid/food, recent intake of
STOMACH food
– Obstruction in pyloric area, food
particles and fluid cannot pass to
duodenum, accumulation in the upper
portion
■ Tympanitic
– In supine position; fluid dependent settle
posterior and air floats anteriorly
PERCUSSION: ■ Hypertympanitic
– Possible obstruction involving stomach
STOMACH and duodenum
– Pathologic causes:
■ Pyloric stenosis
■ Polyp
■ Mass
■ Duodenal ulcers
■ Intestinal adhesions
PALPATION
PALPATION ■ Ball of fingertips are used for palpation
■ May be single handed or bimanual technique
■ Does not give the diagnosis and therefore
needs to be accompanied with other
information such as HPI
■ Adds supporting details for the diagnosis
 Light palpations

PALPATION
Deep palpations
LIGHT ■ To identify
– Consistency of the abdominal wall
PALPATION – Areas of superficial abdominal
tenderness
– Superficial masses
 ■ With the fingers approximated, press the finger
pads gently into the abdomen with a dipping motion
to depth of about 1cm
LIGHT ■ Lift and move the examining fingers randomly over
PALPATION each quadrant
■ Describe the findings
PROCEDURE – Consistency of the abdomen
■ Soft
■ Firm
■ Rigid
– Palpable mass
■ Size (cm)
■ Location
■ Tender or non tender
■ Movable or fixed
DEEP ■ To elicit deep tenderness
■ To detect masses
PALPATION ■ To palpate for possible enlargement of liver,
spleen, kidneys and describe them
accordingly
 ■ Single-handed technique
– Using the palmar surface of the approximated fingers, press
DEEP the abdomen to the depth of about 4-5cm, then glide the
fingers back and forth
PALPATION – Palpate each of the quadrant

PROCEDURE ■ Double-handed technique

– Place the left hand on top of the right hand
– The fingers of the left hand should press on the distal
phalanges of the right hand
– The left hand reinforces the palpation by exerting pressure
on the right hand while the right hand feels for the organs,
masses and other abnormalities
– Press the abdomen to a depth of about 4-5cm then glide the
fingers back and forth
– Palpate each of the quadrant
 ■ Bimanual palpation of the Right Upper Quadrant
– Press the right hand upward while the left is lifting the
back
DEEP ■ Hooking technique
PALPATION – For obese

PROCEDURE – Stand at the right side of the patient facing the feet
– Place both hands side by side below the border of liver
dullness
– Press and ask patient to inspire deeply
■ Bimanual palpation of the Left Upper Quadrant
– Press right hand over left axillary area and left hand at
left middle axillary line
– Bring both hands close together during deep
inspiration
 HOOKING
TECHNIQU
E
DEEP
PALPATION
PROCEDURE

BIMANUA
L
PALPATIO
N
PALPATION ■ Place your left hand behind the patient, parallel
to and supporting the right 11th and 12th ribs and
LIVER adjacent soft tissues below
■ Press left hand upward
■ Place your right hand on the patient’s abdomen
lateral to the rectus muscle, with your fingertips
well below the lower border of the liver dullness
■ Press gently in and up
■ Ask the patient to take a deep breath
■ On inspiration, the liver is palpable 3cm below
the right costal margin in the midclavicular line
 ■ With your left hand, reach over and around the
PALPATION patient to support and press forward the lower
SPLEEN left rib cage and adjacent soft tissue.
■ With your right hand below the left costal
margin, press in toward the spleen.
■ Ask the patient to take a deep breath.
■ Try to feel the tip or edge of the spleen as it
comes down to meet your fingertips
PALPATION ■ Simultaneously press medially and
downward with the left hand and inward and
SPLEEN upward with the right hand while the patient
is instructed to take a deep breath.
■ Repeat with the patient lying on the right
side with legs somewhat flexed at the hips
and knees.
■ In this position, gravity may bring the spleen
forward and to the right into a palpable
location.
 ■ Right kidney
– Lay the patient supine and stand on his right side.
– Place the flat of your left hand behind the subject’s
PALPATION right flank supporting the right costo-vertebral
angle (also called the renal angle) lateral to the
KIDNEY erector muscle of the spine (Figure 10).
– Place your right palm flat across the subject’s right
lumbar region at the same level as your left hand
and just lateral to the rectus muscle.
– Press the two hands together firmly and ask the
patient to breath in deeply to see if you can feel the
lower pole of the right kidney.
– Sit the patient up, place your left hand flat against
the costo-vertebral angle and pound on the back of
your hand with your right fist to check for
tenderness.
 ■ Left kidney
– Lay the subject supine and stand on his right
PALPATION side.
– Reach across him and place your left hand
KIDNEY behind his left lumbar region (left flank)
supporting the left costo-vertebral angle lateral
to the erector muscle of the spine.
– Place the right hand across the subject’s left
flank opposite your left hand.
– Press the hands firmly together while the patient
is taking a deep breath in an attempt to feel the
descending left kidney.
– Sit the patient up, place your left hand flat
against the costovertebral angle and pound on
the back of your hand with your right fist to
check for tenderness.
TYPE OF ■ Simple direct tenderness
– Inflammation of the underlying structure
TENDERNESS – The quadrant where there is direct
tenderness is more likely due to
pathologic organ located on that
quadrant
– When checking for direct tenderness,
deep palpation could increase the
intraabdominal pressure abruptly
TYPE OF ■ Rebound tenderness
– This is a test for peritoneal irritation.
TENDERNES – Warn the patient what you are about to
S do.
– Press deeply on the abdomen with your
hand.
– After a moment, quickly release
pressure.
– If it hurts more when you release, the
patient has rebound tenderness
TYPE OF ■ Referred pain
– Tenderness at a nearby area where deep
TENDERNES palpation was done

S – Rovsing maneuver
■ Seen in acute appendicitis
■ Pain is felt at LLQ when RLQ is
pressed
DIFFERENT PATHOLOGIC PROBLEMS

■ Epigastric region
– Early acute appendicitis
– Perforating pelvic ulcers
– Peptic ulcer
– Acute pancreatitis
– Occlusion of the superior
mesenteric arteries
– Dissecting aneurysm
– Acute gastric dilatation
DIFFERENT PATHOLOGIC PROBLEMS

■ Right upper quadrant

– Cholelithiasis
– Cholecystitis
■ Murphy’s sign
– (+) in acute
cholecytitis
– (-) in cholelithiasis
– Duodenal ulcer
– Ruptured liver
DIFFERENT PATHOLOGIC
PROBLEMS
■ Left upper quadrant
– Spleen infarction
– Splenic rupture
– Left pyelonephritis
■ Right lower quadrant
– Acute appendicitis
– Perforated appendicitis
– Meckel’s diverticulum
– Regional or terminal ileitis
– Perforated duodenal ulcer
– Diverticulitis
– Ovarian pathology
■ Suprapubic region
– Urinary bladder rupture
– Pelvic inflammatory disease
 SIGNS SPECIFIC FOR ABDOMEN PATHOLOGY
SIGN DESCRIPTION ASSOCIATED CONDITION
Cullen Ecchymosis around umbilicus Hemoperitoneum, pancreatitis, ectopic pregnancy

Grey Turner Ecchymosis of flanks Hemoperitoneum, pancreatitis

Kehr Abdominal pain w/radiation to shoulders Splenic rupture, renal calculi, ectopic pregnancy

Murphy Abrupt cessation of inspiration on palpation Cholecystitis

of gallbladder
Blumberg Rebound tenderness Peritoneal irritation, appendicitis
Markle (heel jar) Stand with straightened knees, raises up on Peritoneal irritation, appendicitis
toes, relaxes, allows heels to hit floor, thus
jarring the body

Rovsing RLQ pain intensified by LLQ pressure Peritoneal irritation, appendicitis

Aaron Pain or distress in the area of the patient’s Appendicitis

heart or stomach on palpation of Mcburney’s
point
McBurney Rebound tenderness and sharp pain when Appendicitis
Mcburney’s point is palpated
THANK YOU
DOCTORS!