Describing the Abdomen

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 5

Describing the AbdomenDescribing the Abdomen

Abdomen Abdomen split into split into quadrants to quadrants to help organize help organize organs. organs.


Describing the AbdomenDescribing the Abdomen

The The abdomen abdomen can also be can also be split into 9 split into 9 sections as sections as well. well.


Right Upper Quadrant (RUQ)Right Upper Quadrant (RUQ)

Liver & GallbladderLiver & Gallbladder

Head of PancreasHead of Pancreas

DuodenumDuodenum

Right adrenal glandRight adrenal gland

Hepatic flexure of colonHepatic flexure of colon

Portion of right kidneyPortion of right kidney


Right Lower Quadrant (RLQ)Right Lower Quadrant (RLQ)

AppendixAppendix

Ascending colonAscending colon

OvaryOvary

Right ureterRight ureter

Bladder Bladder

UterusUterus


Left Upper Quadrant (LUQ)Left Upper Quadrant (LUQ)

SpleenSpleen

StomachStomach

PancreasPancreas

Left lobe of liverLeft lobe of liver

Splenic flexure of colonSplenic flexure of colon

Portions of transverse and descending colonPortions of transverse and descending colon


Left Lower Quadrant (LLQ)Left Lower Quadrant (LLQ)

Lower left kidneyLower left kidney

Sigmoid colonSigmoid colon

OvaryOvary

Left ureterLeft ureter

Descending colonDescending colon

Bladder Bladder

UterusUterus


Assessing the AbdomenAssessing the Abdomen

Chief complaintChief complaint

History of present illnessHistory of present illness

Past medical historyPast medical history

Family historyFamily history

Personal/Social historyPersonal/Social history

Physical ExamPhysical Exam

DifferentialDifferential

LabsLabs


Importance of History Present IllnessImportance of History Present Illness

GI versus cardiac causesGI versus cardiac causes

Clues to DifferentialClues to Differential

Abdominal “Review of Systems”Abdominal “Review of Systems”

Seven attributes of a symptomSeven attributes of a symptom


Review of Systems for the AbdomenReview of Systems for the Abdomen

Abdominal painAbdominal pain

IndigestionIndigestion

NauseaNausea

VomitingVomiting

DiarrheaDiarrhea

ConstipationConstipation

JaundiceJaundice

DysuriaDysuria

Urinary frequencyUrinary frequency

HematuriaHematuria


Past Medical HistoryPast Medical History

Gastrointestinal disordersGastrointestinal disorders Urinary Tract InfectionsUrinary Tract Infections SurgeriesSurgeries Medications/ImmunizationsMedications/Immunizations Trauma/InjuryTrauma/Injury Blood transfusionsBlood transfusions HepatitisHepatitis CancerCancer

• Review of Related History


Family HistoryFamily History

Familial Mediterranean FeverFamilial Mediterranean Fever Inflammatory bowel diseaseInflammatory bowel disease Familial cancer syndromesFamilial cancer syndromes Congenital malformationsCongenital malformations Cystic fibrosis, Celiac’sCystic fibrosis, Celiac’s Kidney diseaseKidney disease Gallbladder diseaseGallbladder disease



Personal and Social HistoryPersonal and Social History

NutritionNutrition

LMP (first day of last menstrual period)LMP (first day of last menstrual period)

Stressful life eventsStressful life events

Travel /Exposure to infectious diseasesTravel /Exposure to infectious diseases

Sexual historySexual history

Use of alcohol and/or illicit drugsUse of alcohol and/or illicit drugs

Tobacco useTobacco use



Pregnant WomenPregnant Women

Urinary symptomsUrinary symptoms Frequency, urgency, burning, suprapubic painFrequency, urgency, burning, suprapubic pain Back painBack pain

Abdominal painAbdominal pain ContractionsContractions

Onset, frequency, duration, intensityOnset, frequency, duration, intensity Leakage of fluid, bloodLeakage of fluid, blood



Older AdultsOlder Adults

Urinary Tract InfectionsUrinary Tract Infections

ConstipationConstipation

IndigestionIndigestion

Dietary habitsDietary habits



Abdominal ExamAbdominal Exam

PreparationPreparation

InspectionInspection

AuscultationAuscultation

PercussionPercussion

PalpationPalpation


Preparation for the Abdominal ExamPreparation for the Abdominal Exam

Empty bladderEmpty bladder

PositioningPositioning

Abdomen exposureAbdomen exposure

Visualize anatomyVisualize anatomy

Warm hands & stethoscope Warm hands & stethoscope

Approach from the rightApproach from the right

Remember chief complaintRemember chief complaint

Watch faceWatch face


Inspection (1)Inspection (1)

Skin characteristics: color, striae, rashes, Skin characteristics: color, striae, rashes, lesions, scars, dilated veinslesions, scars, dilated veins

Umbilicus: location, displacement, Umbilicus: location, displacement, inflammationinflammation

Contour: rounded, flat, scaphoidContour: rounded, flat, scaphoid

Symmetry: symmetric, bulges, distensionSymmetry: symmetric, bulges, distension

Surface Motion: pulsations, peristalsisSurface Motion: pulsations, peristalsis


AuscultationAuscultation

Bowel sounds: frequency, characterBowel sounds: frequency, character

Vascular sounds: bruits, venous humsVascular sounds: bruits, venous hums


Percussion (1)Percussion (1)

Assess size & density of organsAssess size & density of organs

Detect presence of fluid, air, masses, Detect presence of fluid, air, masses, tendernesstenderness

Can be done independently or concurrently Can be done independently or concurrently with palpationwith palpation



All quadrants: tympany vs dullnessAll quadrants: tympany vs dullness

Liver span: at right MCL and at the MSL if Liver span: at right MCL and at the MSL if enlargedenlarged

Spleen percussion sign: lowest left ICS Spleen percussion sign: lowest left ICS before & after deep breathbefore & after deep breath

Gastric bubble: left lower anterior rib cage, Gastric bubble: left lower anterior rib cage, left epigastric arealeft epigastric area

Kidneys: costovertebral angleKidneys: costovertebral angle



If suspect ascites as result of percussion of If suspect ascites as result of percussion of abdominal wall may perform two additional abdominal wall may perform two additional tests: Shifting Dullness Test and the Fluid tests: Shifting Dullness Test and the Fluid Wave Test Wave Test


Palpation (1)Palpation (1)

Evaluation of organs for: size, shape, Evaluation of organs for: size, shape, consistency, tendernessconsistency, tenderness

Evaluate umbilical ringEvaluate umbilical ring

Palpate for pulsation of abdominal aortaPalpate for pulsation of abdominal aorta

Detection of massesDetection of masses



Light Palpation: all 4 quadrants; identify Light Palpation: all 4 quadrants; identify muscular resistance, tenderness, massesmuscular resistance, tenderness, masses

Deep palpation: all 4 quadrants; delineate Deep palpation: all 4 quadrants; delineate organs and detect deeper massesorgans and detect deeper masses

Mass: location, size, shape, consistency, Mass: location, size, shape, consistency, tenderness, pulsation, mobility, movement tenderness, pulsation, mobility, movement with respiration, superficial or intra-abdominalwith respiration, superficial or intra-abdominal



Liver: palpate lower border of right costal Liver: palpate lower border of right costal marginmargin

Aorta: for pulsationAorta: for pulsation

Bladder: distensionBladder: distension

Gallbladder, Spleen, Kidney not often done Gallbladder, Spleen, Kidney not often done unless physician suspects abnormalityunless physician suspects abnormality


Additional Abdominal TestsAdditional Abdominal Tests

Rebound tendernessRebound tenderness

Iliopsoas muscle testIliopsoas muscle test

Obturator muscle testObturator muscle test

• Examination and Findings


Abdominal Signs/Associated Abdominal Signs/Associated ConditionsConditions

Blumberg (rebound tenderness)Blumberg (rebound tenderness)

Cullen: ecchymosis around umbilicusCullen: ecchymosis around umbilicus

Grey Turner: ecchymosis of flanksGrey Turner: ecchymosis of flanks

Kehr: abdominal pain radiating to left shoulderKehr: abdominal pain radiating to left shoulder

Markel (heel jar test): up on toes, fall back on heelsMarkel (heel jar test): up on toes, fall back on heels

McBurney: rebound tenderness,pain over appendix McBurney: rebound tenderness,pain over appendix

Murphy: abrupt cessation of respiration when Murphy: abrupt cessation of respiration when gallbladder palpatedgallbladder palpated


Differential by Anatomic Region-RUQDifferential by Anatomic Region-RUQ

Duodenal ulcerDuodenal ulcer

HepatomegalyHepatomegaly

HepatitisHepatitis

PneumoniaPneumonia

CholecystitisCholecystitis


Differential by Anatomic Region-LUQDifferential by Anatomic Region-LUQ

Ruptured spleenRuptured spleen

Gastric ulcerGastric ulcer

Aortic aneurysmAortic aneurysm

Perforated colonPerforated colon

PneumoniaPneumonia


Differential by Anatomic Region-Differential by Anatomic Region-Periumbilical RegionPeriumbilical Region

Intestinal obstructionIntestinal obstruction

Acute pancreatitisAcute pancreatitis

Early appendicitisEarly appendicitis

Mesenteric thrombosisMesenteric thrombosis

Aortic aneurysmAortic aneurysm

DiverticulitisDiverticulitis


Differential by Anatomic Region-RLQDifferential by Anatomic Region-RLQ

AppendicitisAppendicitis

Ovarian cyst or mass/salpingitisOvarian cyst or mass/salpingitis

Ruptured ectopic pregnancyRuptured ectopic pregnancy

Renal/ureteral stoneRenal/ureteral stone

Strangulated herniaStrangulated hernia

Perforated cecum/regional ileitisPerforated cecum/regional ileitis



Differential by Anatomic Region-LLQDifferential by Anatomic Region-LLQ

Ovarian cyst or mass/salpingitisOvarian cyst or mass/salpingitis

Ruptured ectopic pregnancyRuptured ectopic pregnancy


Renal/ureteral stoneRenal/ureteral stone

Strangulated herniaStrangulated hernia

Ulcerative colitisUlcerative colitis

Perforated colon/regional ileitisPerforated colon/regional ileitis


Acute AppendicitisAcute Appendicitis

Pain characteristic: periumbilical or Pain characteristic: periumbilical or epigastric; later localized to RLQ, +McBurneyepigastric; later localized to RLQ, +McBurney

Associated findings: anorexia, nausea, Associated findings: anorexia, nausea, possible vomiting, low grade fever, guarding, possible vomiting, low grade fever, guarding, +rebound tenderness, +iliopsas, +obturator, +rebound tenderness, +iliopsas, +obturator, +McBurney, +Markle+McBurney, +Markle

Peritonitis possible if rupture occurs: Peritonitis possible if rupture occurs: guarding, shallow respirations, hypotension guarding, shallow respirations, hypotension or shock, reduced or absent bowel sounds; or shock, reduced or absent bowel sounds; can be life-threateningcan be life-threatening


Acute CholecystitisAcute Cholecystitis

Pain: severe pain in RUQ, epigastric or Pain: severe pain in RUQ, epigastric or umbilical pain; lasting 2-4 hours; after meals umbilical pain; lasting 2-4 hours; after meals and especially after fatty meal; may be and especially after fatty meal; may be referred to right subscapular areareferred to right subscapular area

Associated findings: RUQ tenderness & Associated findings: RUQ tenderness & rigidity, +Murphy sign, palpable gallbladder, rigidity, +Murphy sign, palpable gallbladder, anorexia, vomiting, flatulence, fever; possible anorexia, vomiting, flatulence, fever; possible jaundicejaundice


Acute PancreatitisAcute Pancreatitis

Pain: dramatic, sudden, excruciating LUQ, Pain: dramatic, sudden, excruciating LUQ, epigastric, or umbilical pain; may be present epigastric, or umbilical pain; may be present in one or both flanks with possible in one or both flanks with possible ecchymosis; pain may be referred to left ecchymosis; pain may be referred to left shouldershoulder

Associated findings: epigastric tenderness, Associated findings: epigastric tenderness, vomiting, fever, shock; +Grey Turner and vomiting, fever, shock; +Grey Turner and Cullen signs which occur 2-3 days after onsetCullen signs which occur 2-3 days after onset


Ectopic PregnancyEctopic Pregnancy

Pain: history of vague abdominal pain Pain: history of vague abdominal pain followed by sudden severe abdominal followed by sudden severe abdominal tenderness in LQ, especially on involved sidetenderness in LQ, especially on involved side

Associated findings: hypogastric tenderness, Associated findings: hypogastric tenderness, symptoms of pregnancy, spotting, missed symptoms of pregnancy, spotting, missed period, mass on bimanual pelvic exam; if period, mass on bimanual pelvic exam; if ruptured: shock, rigid abdominal wall, ruptured: shock, rigid abdominal wall, distension, + Kehr, + Cullendistension, + Kehr, + Cullen

Mittleschmertz: pain associated w/ovulationMittleschmertz: pain associated w/ovulation


Acute HepatitisAcute Hepatitis

Pain: general abdominal discomfort; malaisePain: general abdominal discomfort; malaise

Associated findings: jaundice, clay-colored Associated findings: jaundice, clay-colored stools and dark urine which may preceed stools and dark urine which may preceed jaundice by 1 to 5 days, enlarged liverjaundice by 1 to 5 days, enlarged liver

Patients with cirrhosis: will also have ascites, Patients with cirrhosis: will also have ascites, prominent abdominal vasculature, cutaneous prominent abdominal vasculature, cutaneous spider angiomas, generalized itchingspider angiomas, generalized itching


Perforated Gastric or Duodenal UlcerPerforated Gastric or Duodenal Ulcer

Pain: abrupt RUQ; may be referred to Pain: abrupt RUQ; may be referred to shouldersshoulders

Associated findings: abdominal free air and Associated findings: abdominal free air and distension with increased resonance over distension with increased resonance over liver; tenderness in epigastrum or RUQ; rigid liver; tenderness in epigastrum or RUQ; rigid abdominal wall, rebound tenderness; abdominal wall, rebound tenderness; hematemesis, melena, hypotension, hematemesis, melena, hypotension, increased pulse rate; “acute abdomen” is a increased pulse rate; “acute abdomen” is a life-threatening eventlife-threatening event


Abdominal Aortic AneurysmAbdominal Aortic Aneurysm

Pain: painless but pain may indicate Pain: painless but pain may indicate imminent rupture; steady throbbing midline imminent rupture; steady throbbing midline pain over aneurysm which may radiate to pain over aneurysm which may radiate to back, flankback, flank

Associated findings: nausea, vomiting, Associated findings: nausea, vomiting, prominent aortic pulsation, bruit and or massprominent aortic pulsation, bruit and or mass

Life-threatening even if occurs in hospital Life-threatening even if occurs in hospital settingsetting


PyelonephritisPyelonephritis

Pain: flank pain, back painPain: flank pain, back pain

Associated findings: malaise, dysuria, Associated findings: malaise, dysuria, nocturia, urinary frequency, possible fever, + nocturia, urinary frequency, possible fever, + costovertebral angle tendernesscostovertebral angle tenderness


Renal CalculiRenal Calculi

Pain: intense flank pain extending to groin & Pain: intense flank pain extending to groin & genital area; may be episodicgenital area; may be episodic

Associated findings: fever, hematuria, + KehrAssociated findings: fever, hematuria, + Kehr


Irritable Bowel SyndromeIrritable Bowel Syndrome

Pain: crampy, variable hypogastric pain; Pain: crampy, variable hypogastric pain; associated with abdominal bloating, associated with abdominal bloating, distension; + bowel soundsdistension; + bowel sounds

Associated symptoms: flatus, constipation or Associated symptoms: flatus, constipation or diarrhea; may see mucous in stool; relief with diarrhea; may see mucous in stool; relief with passage of flatus or bowel movementpassage of flatus or bowel movement



Pain: epigastric, radiating down left side of Pain: epigastric, radiating down left side of abdomen especially after eating; may be abdomen especially after eating; may be referred to backreferred to back

Associated findings: tenderness on Associated findings: tenderness on palpation, borborygmus, flatulence, diarrhea, palpation, borborygmus, flatulence, diarrhea, possibly dysuriapossibly dysuria


Acute DiarrheaAcute Diarrhea

Pain: abrupt onset of crampy painPain: abrupt onset of crampy pain

Associated findings: increased bowel Associated findings: increased bowel sounds, diarrhea, nausea, vomiting, fever, sounds, diarrhea, nausea, vomiting, fever, and tenesmus; consider food poisoning if and tenesmus; consider food poisoning if develops in 2 or more following ingestion of develops in 2 or more following ingestion of same foodsame food


HerniaHernia

Pain: localized pain that increases with lifting Pain: localized pain that increases with lifting or exertionor exertion

Associated findings: hernia on physical Associated findings: hernia on physical exam, history of abdominal trauma, surgeryexam, history of abdominal trauma, surgery


ReferencesReferences

Mosby’s Guide to Physical Examination, 6Mosby’s Guide to Physical Examination, 6 thth Edition. Chapter 17 pp 521-578.Edition. Chapter 17 pp 521-578.

Bates’ Guide to Physical Examination and Bates’ Guide to Physical Examination and History Taking. Chapter 9 pp 317-366.History Taking. Chapter 9 pp 317-366.

University of California, San Diego “A University of California, San Diego “A Practical Guide to Clinical Medicine” Practical Guide to Clinical Medicine” Accessed online 02/09/07 at Accessed online 02/09/07 at medicine.ucsd.edu/clinicalmedicine/medicine.ucsd.edu/clinicalmedicine/

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Describing the Abdomen

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