The Abdomen: History & Physical Exam

1. The Abdomen:History & Physical Exam Dr. Gwen Hollaar, Dr. Lanice Jones Dr. Robert Lee Lao 2006

2. Objectives • Review important information students need to obtain on history for the GI and GU systems • How to teach abdominal exam • How to teach genital and gynecological exam

3. History Taking – Abdominal Complaints • When patients present with abdominal symptoms, pain is a common symptom • Remember to ask the following questions about the pain (WWQQAAAB) • Where is the pain? • When do you get the pain? (Example: before or after eating, before or after a bowel movement?) • Quality: sharp, dull, stabbing, cramping / severity • Quantity: constant or intermittent (how frequent) • Aggravate: does anything make the pain worse? • Alleviate: does anything make the pain better? • Belief – what does the patient think is causing the pain

4. Abdominal Pain Peptic ulcer Acute cholecystitis Perforated esophagus Myocardial infarction Acute cholecystitis Duodenal ulcer Hepatitis Congestive hepatomegaly Pyelonephritis Appendicitis Rt pneumonia / Pulmonary embolus Splenic rupture / Splenomegaly Gastric ulcer Perforated colon Pyelonephritis Lt pneumonia / Pulmonary embolus GI Obstruction Acute pancreatitis Early appendicitis Appendicitis Salpingitis / Tubo-ovarian abscess Ruptured ectopic pregnancy Renal / Ureteric / Bladder stone UTI Mesenteric adenitis Meckel’s diverticulitis Psoas abscess Perforated colon Inguinal hernia Salpingitis / Tubo-ovarian abscess Ruptured ectopic pregnancy Renal / Ureteric / Bladder stone UTI Perforated colon Inguinal hernia

5. Associated Symptoms of the GI system • Difficulty swallowing (dysphagia) • Fluids and/or solids • Where does it feel like food is getting stuck • Associated pain with swallowing or not • Vomiting • Bilious / nonbilious / fecal / hematemesis • Projectile / nonprojectile • Heartburn or Indigestion • These can be vague symptoms…. Be sure to get a complete description of this discomfort to better determine its etiology (cause)

6. Associated Symptoms of the GI system • Jaundice • Associated with pain or not • History of drinking large amounts of alcohol • History of travel and diet • Change in Bowel Habits • Frequency • What is their normal bowel habit pattern • Has this recently changed • Stool appearance • Colour: pale, dark brown, black (melena) • Formed, poorly formed, watery • Mucous • Passing visible worms or fragments

7. Associated Symptoms of the GI system • Bleeding per rectum (hematochezia) • Color of blood (bright red or dark red) • Only with bowel movements or any time • Associated with perianal pain or perianal swelling • Loss of weight or loss of appetite • Approximate weight loss and over how much time • Abdominal distention • Fluctuates or constant

8. Associated Symptoms of the GU system • Dysuria: pain on passing urine • Frequency • Polyuria or oliguria or anuria • Nocturia: need to pass urine at night • Urgency • Change in force of urinatation • Difficulty in beginning or maintaining urinary stream • Complete or incomplete bladder emptying • Incontinence of urine • Hematuria: painful or painless • Abdominal or flank pain

9. Associated Symptoms of the GU system • Gynecological history: • Menstrual history • Last menstrual period • Duration of menstrual flow • Amount of menstrual flow • Pain with menstruation • Intermenstrual or postcoital bleeding • Abnormal vaginal discharge (get description)

10. Abdominal Examination • Inspection • Auscultation • Percussion • Palpation (Some textbooks suggest changing to this order because palpation is often the most painful in patients with abdominal pain).

11. Remember extra-abdominal inspection Jaundice Sclera Under the tongue Palm of hands Inspection

12. Inspection for Other signs of Liver Disease • Skin • Jaundice • Spider nevi • Caput medusa • Peripheral edema • Hands • Palmer erythema • Dupytren’s contracture • Breasts & Genitalia • Gynecomastia • Testicular atrophy • Neurologic • Flapping tremor

13. Manifestations of Chronic Liver Disease Ascites Gynecomastia Edema Spider Nevi

14. Abdominal inspection Presence of surgical scars Exaggerated collateral veins on abdominal wall Shape and symmetry of abdomen Scaphoid or distended Bulging flanks (may suggest ascites) Masses or local areas of swelling Remember this includes the groin (ie. lymphadenopathy or hernias) Inspection

15. Inspection of Abdomen Caput Medusa (sign of portal hypertension / cirrhosis) Umbilical Hernia

16. Auscultation • Bowel Sounds • Present • Tinkling bowel sounds suggest mechanical obstruction • Absent • Suggests ileus • Abdominal Bruits • Check at renal arteries and at bifurcation of aorta

17. Abdominal Exam – Think Anatomically

18. Abdominal Exam – Think Anatomically

19. Percussion • Percuss over all 4 quadrants to determine if there is tenderness • Localized areas of tenderness on percussion suggests peritonitis or peritoneal irritation

20. Abdominal Pain • You can remind your students that the abdominal cavity has two peritoneum • Visceral peritoneum: lines solid organs and bowel • Parietal peritoneum: lines the abdominal cavity on the inside of the abdominal wall • Stimulus to visceral peritoneum causes diffuse abdominal pain • Causes include: • Visceral (i.e. bowel) distention or swelling • Strong contraction of bowel • Stimulus to parietal peritoneum causes localized abdominal pain • Causes include irritation to parietal peritoneum • Inflamed or purulent internal organs (i.e. appendicitis) • Perforation of hollow viscous • Hemoperitoneum

21. Percussion • After percussing all 4 quadrants, particular areas you want to percuss include: • Liver • Spleen • Percuss for ascites or distended bladder (suprapubic region) if suspected • General principles of percussion • Sound will be dull over solid organs and tympanic (hollow) over air-filled organs • Percuss from resonant area to dull area

22. Percussion • Liver percussion • Assess of liver size • Percuss along mid-clavicular line from chest towords subcostal area to determine upper border of liver • Percuss along mid-clavicular line from right lower quadrant superiorly to determine lower border of liver • Measure the area that is dull as this is the measurement of the liver span

23. Percussion • Spleen percussion • Assess for enlarged spleen • Percuss over Traube’s space • If dull sound, the spleen is enlarged • If tympanic (hollow) sound, the spleen is not enlarged • You can also percuss from RLQ to LUQ to assess when there is a transition from a hollow sound to a dull sound Traube’s space

24. Percussion for Ascites

25. Percussion for Ascites • Patient is lying supine • Percuss from near the umbilicus laterally • Note where the sound changes from tympanic (hollow) to dull • Dullness is where the intra-abdominal fluid level is located while the patient lies supine

26. Percussion for Ascites • Now roll patient to the side • Percuss from around the umbilicus laterally • Note where the sound changes from tympanic (hollow) to dull • Dullness is where the intra-abdominal fluid level now is located while the patient lies on his side • If the line has shifted with patient position, the patient probably has ascites

27. Palpation • First palpate all quadrants to assess for: • Tenderness • Masses • It is best to start palpation in quadrant where there is least tenderness and end in quadrant where there is most tenderness • You should also palpate for liver and spleen

28. Palpation of Liver • Begin in mid-clavicular line (or just lateral to rectus abdominis muscle) at least 10 cm below costal margin (i.e. below where the liver edge should be) • Use your left hand to push anteriorly against back • Use your right hand to gently press in and upwards and have patient take a deep breath • Move your hand more superiorly, press again and have patient take another deep breath • The liver edge will slide under your fingers when the patient takes a deep breath • The liver edge in not usually palpable in a patient with a normal liver

29. Palpation of Spleen • Begin in right lower quadrant so that an enlarged splenic edge will brush against your fingers • Use your left hand to push anteriorly against back • Use your right hand to gently press in and upwards and have patient take a deep breath • Move your hand more superiorly, press again and have patient take another deep breath • The splenic edge will slide under your fingers when the patient takes a deep breath • The splenic edge will not be palpable in a patient with a normal spleen Palpate upwards in this direction, from RLQ to LUQ

30. Palpation for Ascites – Fluid Wave • You need an assistant or have the patient help you • Have your assistant (or the patient) place their hand on the midline of the abdomen • This prevents you from feeling any transmitted wave through the subcutaneous fat • Use one hand to tap the lateral abdomen while the other hand is pressed gently against the opposite lateral abdomen to feel for the transmitted fluid wave. • Fluid will transmit the tap, air does not This examination can be difficult to know for sure if there is ascites or not.

31. Kidney examination • Examine for tenderness over kidneys by gently tapping the flanks with your fist while having the patient lean forward

32. Kidney Examination • Physicians do attempt to feel the kidneys by doing a bimanual abdominal exam • Unless the kidney is really enlarged or the patient very thin, it is difficult to actually palpate a kidney

33. Examination of the Groins • Remember: An abdominal exam in NOT complete without examination of the groins

34. Examination of the Groins • Inspection and Palpation with patient supine • Look and feel for masses or swelling (lymphadenopathy or hernias) • Inspection and Palpation with patient standing • Again look and feel for masses or swelling • Have patient perform Valsalva maneuver or cough • Place your index finger over/into external inguinal ring and have patient cough to feel for inguinal hernia

35. Examination of the Anus / Rectum • This is an important part of the examination in patient presenting with abdominal complaints • On examination: • Inspect for external hemorroids or tags • Palpate for masses • Palpate size/consistency of prostate in men • Palpate cervix in women • Feel sphincter tone • Look for blood on your gloved finger

36. Examination of the Anus / Rectum

37. Examination of Male Genitalia • This examination is done selectively depending upon the patient’s symptoms • On examination of the scrotum, you are looking for: • Scrotal tenderness (i.e. epididymitis) • Scrotal swelling (i.e. hydrocele) • Scrotal masses (i.e. testicular tumour)

38. Gynecological Examination • Cover trunk of patient • Have hips and knees flexed and thighs abducted • Need good light • Examine the vulva (inspection and palpation) • Bimanual examination with 2 fingers into vagina and other hand palpating the suprapubic area • Palpate cervix and right and left adnexae • Speculum examination

40. How do you teach examination of personal areas? • How do you teach breast, male genitalia, and gynecological examinations? • Can be difficult thing to teach as teachers, students and patients can be uncomfortable • But these areas DO need to be taught because they are essential clinical skills for students to know • Can teach with patients or with models • When teaching with patients: • Instruct the student ahead of time what the examination consists of or have them read about it (best to do both) • Make sure patient is aware and comfortable with what you will be doing • Demonstrate it on the patient first and then have your student do the examination while you are there so you can correct them as needed

41. Questions or Comments