YOU WERE LOOKING FOR: Abdominal Exam Percussion
Due to congenital defect or weakness in the wall of the vessel. Abdominal - hernia through the abdominal wall. Umbilical - bulging defect at umbilicus. Incisional - defect in abdomen muscles after surgical incision. Must palpate the size of the...
Auscultation of the Abdomen Bowel sounds use diaphragm of stethoscope Bowel sounds are widely transmitted throughout the abdomen. Listening in one spot is usually sufficient. Normal sounds are due to peristaltic activity. Normal sounds consist of...
Bowel sounds cannot be said to be absent unless they are not heard after listening for 3 minutes. Systolic Bruit: An adventitious sound of venous or arterial origin heard on auscultation. Use bell of stethoscope. Listen at midline in middle of epigastrum for whooshing or blowing systolic noise indicative of turbulent blood flow from arterial plaques or aortic aneurysm. Important to listen for if patient has vascular insufficiency of the lower extremities. Listen in bilateral costovertebral angles for renal artery bruits in a hypertensive patient suggestive of renal artery stenosis. Listen over femoral areas for femoral artery bruits, in patients with lower extremity vascular insufficiency. Indicates increased collateral circulation between portal and venous systems as in hepatic cirrhosis.
Friction rubs rare : Right and left upper quandrants Grating sound with respiratory movement Indicates inflammation of peritoneal surface of an organ. Succession splash: Splashing sound indicative of air or fluid in body cavity with shaking individual: normal in s stomach. Percuss lightly in all quandrants. Assess areas of dullness and tympanny. Tympanny usually predominates. Ascertain lower liver border dullness. Percuss from lung resonance downward on right MCL to ascertain upper margin of liver dullness. Normally cm in right in right MCL. The Spleen Searching for the small area of dullness is seldom worthwhile unless you suspect splenomegaly.
Percuss in the lowest interspace in the left mid-axillary line. Have the patient take a deep breath and hold. Repercuss the same area. Change from tympanic to dull indicates splenomegaly. Palpation Gentle horizontal dipping motion with finger tips. Have the patient supine with knees slightly flexed. Identify muscular resistance and abdominal wall tenderness. Deep palpation Place one hand on top of the other. Press with outer hand and feel with inner hand. Palpate tender areas last.
How many places should you listen in? Again, there is no magic answer. At this stage, practice listening in each of the four quadrants and see if you can detect any "regional variations. Three things should be noted: Are bowel sounds present? If present, are they frequent or sparse i. What is the nature of the sounds i. As food and liquid course through the intestines by means of peristalsis noise, referred to as bowel sounds, is generated. These sounds occur quite frequently, on the order of every 2 to 5 seconds, although there is a lot of variability. Bowel sounds in and of themselves do not carry great significance. That is, in the normal person who has no complaints and an otherwise normal exam, the presence or absence of bowel sounds is essentially irrelevant i.
In fact, most physicians will omit abdominal auscultation unless there is a symptom or finding suggestive of abdominal pathology. However, you should still practice listening to all the patients that you examine so that you develop a sense of what constitutes the range of normal. Bowel sounds can, however, add important supporting information in the right clinical setting. In general, inflammatory processes of the serosa i. Inflammation of the intestinal mucosa i. Processes which lead to intestinal obstruction initially cause frequent bowel sounds, referred to as "rushes. This is followed by decreased sound, called "tinkles," and then silence.
Alternatively, the reappearance of bowel sounds heralds the return of normal gut function following an injury. After abdominal surgery, for example, there is a period of several days when the intestines lie dormant. The appearance of bowel sounds marks the return of intestinal activity, an important phase of the patient's recovery. Bowel sounds, then, must be interpreted within the context of the particular clinical situation. They lend supporting information to other findings but are not in and of themselves pathognomonic for any particular process. After you have finished noting bowel sounds, use the diaphragm of your stethoscope to check for renal artery bruits, a high pitched sound analogous to a murmur caused by turbulent blood flow through a vessel narrowed by atherosclerosis.
The place to listen is a few cm above the umbilicus, along the lateral edge of either rectus muscles. Most providers will not routinely check for bruits. However, in the right clinical setting e. When listening for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal structures. Atherosclerosis distal to the aorta i. Blood flow through the aorta itself does not generate any appreciable sound. Thus, auscultation over this structure is not a good screening test for the presence of aneurysmal dilatation. Percussion: The technique for percussion is the same as that used for the lung exam. First, remember to rub your hands together and warm them up before placing them on the patient.
Then, place your left hand firmly against the abdominal wall such that only your middle finger is resting on the skin. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your right middle finger, using the previously described floppy wrist action see under lung exam. There are two basic sounds which can be elicited: Tympanitic drum-like sounds produced by percussing over air filled structures. Dull sounds that occur when a solid structure e. This would certainly be supported by other historical and exam findings. Abdominal Percussion What can you really expect to hear when percussing the normal abdomen? The two solid organs which are percussable in the normal patient are the liver and spleen. In most cases, the liver will be entirely covered by the ribs. Occasionally, an edge may protrude a centimeter or two below the costal margin. The spleen is smaller and is entirely protected by the ribs.
To determine the size of the liver, proceed as follows: Start just below the right breast in a line with the middle of the clavicle, a point that you are reasonably certain is over the lungs. Percussion in this area should produce a relatively resonant note. Move your hand down a few centimeters and repeat. After doing this several times, you will be over the liver, which will produce a duller sounding tone. Continue your march downward until the sound changes once again. This may occur while you are still over the ribs or perhaps just as you pass over the costal margin.
At this point, you will have reached the inferior margin of the liver. The total span of the normal liver is quite variable, depending on the size of the patient between 6 and 12 cm. Don't get discouraged if you have a hard time picking up the different sounds as the changes can be quite subtle, particularly if there is a lot of subcutaneous fat. The resonant tone produced by percussion over the anterior chest wall will be somewhat less drum like then that generated over the intestines. While they are both caused by tapping over air filled structures, the ribs and pectoralis muscle tend to dampen the sound.
Speed percussion, as described in the pulmonary section, may also be useful. Orient your left hand so that the fingers are pointing towards the patients head. Percuss as you move the hand at a slow and steady rate from the region of the right chest, down over the liver and towards the pelvis. This maneuver helps to accentuate different percussion notes, perhaps making the identification of the liver's borders a bit more obvious. Percussion of the spleen is more difficult as this structure is smaller and lies quite laterally, resting in a hollow created by the left ribs. When significantly enlarged, percussion in the left upper quadrant will produce a dull tone.
Splenomegaly suggested by percussion should then be verified by palpation see below. The remainder of the normal abdomen is, for the most part, filled with the small and large intestines. Try percussing each of the four quadrants to get a sense of the normal variations in sound that are produced. These will be variably tympanitic, dull or some combination of the above, depending on whether the underlying intestines are gas or liquid filled. The stomach "bubble" should produce a very tympanitic sound upon percussion over the left lower rib cage, close to the sternum. Percussion can be quite helpful in determining the cause of abdominal distention, particularly in distinguishing between fluid a. Of the techniques used to detect ascites, assessment for shifting dullness is perhaps the most reliable and reproducible.
This method depends on the fact that air filled intestines will float on top of any fluid that is present. Proceed as follows: With the patient supine, begin percussion at the level of the umbilicus and proceed down laterally. In the presence of ascites, you will reach a point where the sound changes from tympanitic to dull. This is the intestine-fluid interface and should be roughly equidistant from the umbillicus on the right and left sides as the fluid layers out in a gravity-dependent fashion, distributing evenly across the posterior aspect of the abdomen.
It should also cause a symmetric bulging of the patient's flanks. Mark this point on both the right and left sides of the abdomen and then have the patient roll into a lateral decubitus position i. Repeat percussion, beginning at the top of the patient's now up-turned side and moving down towards the umbilicus. If there is ascites, fluid will flow to the most dependent portion of the abdomen. The place at which sound changes from tympanitic to dull will therefore have shifted upwards towards the umbillicus and be above the line which you drew previously.
Speed percussion described above may also be used to identify the location of the air-fluid interface. If the distention is not caused by fluid e. The models below should help to clarify the concept of shifting dullness. With the "patient" lying flat on their back balloons representing the intestines float on the water representing ascites. When the "patient" turns on their right side, a new air fluid level is established. Shifting Dullness real patient Realize that there has to be a lot of ascites present for this method to be successful as the abdomen and pelvis can hide several hundred cc's of fluid that would be undetectable on physical exam.
Also, shifting dullness is based on the assumption that fluid can flow freely throughout the abdomen. Thus, in cases of prior surgery or infection with resultant adhesion formation, this may not be a very useful technique. Palpation can also be used to check for ascites see below. Palpation: First warm your hands by rubbing them together before placing them on the patient. The pads and tips the most sensitive areas of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures.
You may use either your right hand alone or both hands, with the left resting on top of the right. Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel. Start in the right upper quadrant, 10 centimeters below the rib margin in the mid-clavicular line.
See Examination of the Cardiovascular System for the correct method. Ask the patient to hold their arms out in front of them, elbows extended, and wrists cocked back for a few seconds Look for a tremor which may be caused by alcohol withdrawal Maintaining this position, ask them to fully dorsiflex their wrists and hold that position for ideally thirty seconds whilst you observe. It is best to give these instructions whilst demonstrating the position at the same time. Gently pull down the lower eyelid to look for conjunctival pallor which is a sign of anaemia. The latter is commonly found in ketosis or severe liver disease, and is caused by the accumulation of volatile aromatic substances in the body Neck and Chest Stand behind the patient and palpate for lymphadenopathy in the neck and supraclavicular region see the Examination of the Respiratory System for a detailed description of technique.
If palpation from behind is not possible, or not convenient, then palpation from the front is acceptable. Video on how to examine the lymph nodes Abdominal Examination General examination This is a good point to inspect the skin of the arms and trunk, especially the abdomen, for: Scratch marks pruritis is a feature of cholestatic liver disease Bruising due to impaired clotting factor production in liver failure S Spider naevi Spider naevi are telangiectatic lesions which fill from a central feeding vessel. More than five spider naevi are abnormal and may be caused by excess oestrogen as a result of reduced oestrogen metabolism in chronic liver disease In men, excess oestrogen can also produce gynaecomastia Inspection of the Abdomen Ensure that the patient is completely supine for this part of the examination.
Inspect the abdomen for scars, stomas, striae, sinuses, and fistulae. Sinuses and fistulae are abnormal connections to the skin surface, often resulting from a deep infection, or infection of a surgical tract e. Stomas are important to identify. Pay particular attention to the site of the stoma, the contents of the stoma bag, and whether the stoma is spouted or flush with the skin. This may help you identify the type of stoma. If the abdomen looks distended, ask the patient if this is normal for them. The umbilicus is a useful clue as it is usually sunken in obesity, and flat or everted in other conditions such as ascites. Decide whether the distension is generalised or caused by a localised mass.
Ask the patient to look to the side and cough. Then ask them to raise their head up from the bed by just a few degrees and hold that position for a few seconds before relaxing back into the supine position. A patient with peritonism will find these movements very difficult due to severe pain and the rise in intra-abdominal pressure may accentuate or reveal abdominal wall hernias. Abdominal wall hernias include umbilical, incisional and spigelian hernias. Examination of inguinal and femoral hernias is beyond the remit of this page. Umbilical hernias resulting from incomplete closure of the abdominal wall during foetal development and are often noted at birth as a protrusion at the umbilicus. Umbilical hernias may also appear later in life, particularly after pregnancy, because this region is an area of weakness in the abdominal wall. Incisional hernias, meanwhile, result from abdominal surgery that causes a defect in the abdominal wall.
Spigelian hernias are a rare type of hernia that occurs parallel to the midline of the abdomen, along the edge of the rectus abdominus muscle through the spigelian fascia. Dilated surface veins on the abdominal wall indicate portal hypertension or vena caval obstruction. Peristaltic bowel movements may occasionally be visible if there is bowel obstruction. Palpation Before palpating the abdomen ensure the patient is in the optimal position with their head relaxed on the couch and the the arms relaxed alongside the body. This ensures that the abdominal wall muscles are relaxed and not tense.
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