Abdominal Examination for Internal Medicine

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Introduction:

The abdominal examination follows this sequence: inspection (seeing), palpation (feeling), percussion (tapping), and auscultation (listening). Auscultation is the most important step because you have to get used to listening to normal bowel sounds in the periumbilical region.

Inspection:

There are five main reasons for abdominal distention or obstruction - fat, feces, flatus, fluid, and fetus. With abdominal examination, it is important to rule out these five F's. On inspection, you need to be looking for any scars from previous trauma or surgery, rashes, pulsations, and pigmentation. If you see peristaltic movements going from left to right, the main differential on your list must be pyloric obstruction in pediatric age group. However, if you see peristaltic movements in a step-ladder fashion in an adult patient, think bowel obstruction. One cause of localized abdominal rash is erythema ab igne caused by applying too much heat as an attempt to cure a belly ache. Now, before you document any abdominal-associated symptoms, you need to give the location in terms of the six quadrants of the abdomen.

Nine Abdominal Areas:

nine abdominal areas

Palpation:

Before you palpate, you need to ask the patient to pinpoint the exact location of the abdominal pain. If the patient points to the abdominal area, make sure that is the last area that you palpate. The pathology is usually in the underlying organ where the patient points to, but then of course there can be referred pain. Also, measuring the liver-span in the right iliac fossa going upward is extremely important; for example, if it is large, soft, and tender, it is usually CHF. If the liver is large, nodular, and non-tender, it is malignancy. If the liver is non-tender, nodular, and shrunken in size, it is cirrhosis. If the liver is pulsatile, it is tricuspid regurgitation.

You need to make sure the upper border of the liver is not masked; if the liver border is masked (ie., no sound on precussion), the liver has been shifted down or there is a perforation. Suppose you need to differentiate between an enlarged liver and a liver that is being pushed down and appearing as enlarged. The usual location of the liver is in the right fifth intercoastal margin. Now, you can use the technique of precussion to measure the liver span (which is 12-15 cm), and if the liver span is normal, you know that the liver is normal in size and is only being pushed down from the top. If the liver is not in the right fifth intercoastal margin, it is being masked by air, which travelled from under the right dome of the diaphragm due to a perforation.

Splenic vs nephric lump:

1. If you can palpate a lump, try to reach for the upper margin of the lump. If you cannot feel the top margin i.e., the top margin has no upper limit, it is most likely the spleen. However, you'll be able to feel the upper border of the lump if it is a kidney lump.

2. The kidney or spleen is palpated with one hand in the front and one hand in the back. If you can push the lump from anterior to posterior (and vice-versa) i.e., the lump is bimanually palpable, it is a kidney lump.

3. In the spleen, there is a splenic notch at the tip of the lump, however, there is no notch at the tip of the kidney.

4. There is a colonic band of resonance (due to transverse colon) on top of a nephric lump. The splenic lump is all dull.

Furthermore, you always need to evaluate the patient for costovertebral angle (CVA) tenderness. A costovertebral angle tenderness implies pyelonephritis. Another thing to remember is Mcburney's tenderness, which is tenderness in the right iliac fossa due to acute appendicitis. Mcburney's tenderness originates 2/3rd from the umbilicus and 1/3rd from the anterior superior iliac spine. One of the commonest causes of lawsuits against physicians is a missed appendix disease. The second most common cause of lawsuits against physicians is undetected testicular torsion. The best way to treat acute appendicitis is by surgery.

Percussion:

If you can feel a tympanitic sound while percussing, that's bowel obstruction. If you feel tympanitic sound close to the umbilicus (top), and then dullness after that (bottom), it means water has settled around the umbilical areal. If you palpate and you feel an area of dullness coming out eccentrically from the pelvis while the rest is tympanitic, that is an ovarian mass. Whenever you feel a lump in the abdominal wall, it is important to know whether the lump is in the abdomen (eg., splenomegaly) or is it in the anterior abdominal wall itself (eg., lipoma). One way to do that is to make the patient lie down, then place your hand on the lump and try to make the patient sit up while you push against the lump. If the lump disappears, it is intra-abdominal; if the lump becomes more prominent, it is in the anterior abdominal wall. Two tests can be one for ascities: shifting dullness and fluid thrill. Remember that fluid thrill is only elicited in very tense ascities.

A common cause of abdominal pain in a hospitalized patient is urinary retention. So instead of simply giving a tylenol to a patient with abdominal pain, make sure you palpate and percuss the suprapubic area first. If it is a full bladder, the patient needs a Foley catheter, not a tylenol.

Ideal case:

Suppose a patient comes in with abdominal distention and pain. On abdominal percussion you say it is a bowel obstruction and put your stethoscope on the belly of the patient; there can be two causes: no bowel movement (which indicates paralytic ileus) and hyperdynamic bowel sounds (mechanical bowel obstruction). Thus, there can be two reasons for bowel obstruction: mechanical obstruction or paralytic ileus.

Borborygmus or borborygmos:

This is the term used to describe the growling sounds originating in an empty stomach.

Abdominal distention:

The best way to evaluate abdominal distention is by examining the umbilicus. Normal umbilucis is in the introverted position, however, there may be something pushing the umbilicus if it is everted. When you precuss the abdomen, make sure you percuss parallel to the umbilicus so as to better detect any fluid accumulations. Make sure you know the positions of fluid levels (on the sides) and air-filled intestines (at the top). A fluid-filled vs air-filled cavity produces a different thrill.

Palpating the liver:

When you palpate the liver, you begin with the right iliac fossa going upwards. Make sure you hand is very well molded with the contours of the belly and that your hand moves up and down with expiration and inspiration. Note that you *always* have to palpate the upper border of the liver if the patient has acute abdomen, abdominal pain or hepatomegaly. You can describe the liver as soft, tender, coarse, or pulsatile.

Gallbladder examination:

The gallbladder is usually not palpable, and if it is palpable, it is enlarged. There are only three causes of an enlarged non-tender gallbladder: malignancy in the head of pancreas, malignancy of the gallbladder itself, and mucocele of the gallbladder. There is only one condition which can cause gallbladder tenderness: acute cholecystitis. The sign we look for when we evaluate for acute cholecystitis is called Murphy's sign.

Riedel's lobe:

This is a congenital liver abnormality which causes protrusion of the right lobe of the liver just lateral to the gallbladder. Thus, while thinking you're palpating the gallbladder, you might be palpating the liver as per Riedel's lobe. The gallbladder can be felt at the tip of the 9th intercoastal cartilage. Murphy's sign is basically pain at the height of inspiration (make sure you're looking at the patient's face for sign's of pain). Murphy's sign is positive in cholecystitis.

Kidney examination:

A normal left kidney is never palpable, else the kidney is abnormal. A spleen which has enlarged 2-3 times normal is palpable because the spleen enlarges retroperitoneally first then comes outward. When examining the kidney, make sure one of your hands is on the anterior abdominal wall and the other hand is in the flank of the patient. Push from the anterior abdominal wall and if there is any kidney pathology, it'll hit your hand from the rear flank.

Additional Reading:

Random USMLE Facts

1. Random USMLE Facts volume 1-1
2. Random USMLE Facts volume 2-1
3. Random USMLE Facts volume 3-1
4. Random USMLE Facts volume 4-1
5. Random USMLE Facts volume 5-1
6. Random USMLE Facts volume 6-1
7. Random USMLE Facts volume 7-1
8. Random USMLE Facts volume 8-1
9. Random USMLE Facts volume 9-1
10. Random USMLE Facts volume 10-1
11. Random USMLE Facts volume 11-1
12. Random USMLE Facts volume 12-1

General and Systemic Examinations

1. General Examination for Internal Medicine
2. Jugular Venous Distention Workup
3. ER Chest Pain Workup
4. Format for Patient Presentation
5. Pulmonary Examination for Internal Medicine
6. Cardiac Examination for Internal Medicine
7. Abdominal Examination for Internal Medicine
8. Cranial Nerve Reflexes
9. Motor System Examination
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11. Random Stroke Facts

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3. Video of Pulmonology Examination in a Clinical Setting
4. Video of Musculoskeletal Examination in a Clinical Setting
5. Video of Abdominal Examination in a Clinical Setting
6. Video of HEENT Examination in a Clinical Setting
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8. Video and Description of Weber Hearing Test

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3. USMLE Hematologic Lab Values
4. USMLE Sweat and Urine Lab Values

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