Physical Exam Pearls – 5 (Abdomen)

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So far we’ve surveyed a variety of random tips on performing physical exam of the Eye, HENT, Cardiac, and Pulmonary systems.  Onward to the Belly.

1.  Inspection:  Aside from observing patient demeanor, observation of the abdomen per se is only useful if obscure large masses are noted, or for distention

1a.  Distended Abdomen:  Mnemonic for Differential Dx = “6 F’s”

• Fat
• Fluid (ascites)
• Flatus (obstruction; ruptured bowel)
• Fetus (pregnant)
• Feces
• Fatal Masses (or any masses)

See our posting Weight Gain

2.  Auscultation:  “Hyperactive Bowel Sounds,” which implies intestinal obstruction, sound like “tinkles” or “rushes.”  They’re not simply “louder than usual” normal sounds.

• When I hear lots & lots of gurgles, I chart “Normal B/S”

3.   Auscultation:  Bruits have no specificity, require no work-up, & as such, no mention

• Systolic + Diastolic flank bruit = renal artery stenosis (RAS), but have never heard one.
• Very loud bruit in patient w/ risks for Abdominal Aortic Aneurysm (AAA) warrants ultrasound [men 65-75 who smoke(d) warrant ultrasound anyway]

4.  Unless I suspect Intestinal Obstruction, RAS, or AAA, I don’t auscultate

• Significant ileus (e.g. peritonitis, or post-op) = no bowel sounds x5 min — but who has time for that????
• Might rarely auscultate for the anxious, worried-well patient w/ abdominal c/o, who gets reassured by hands-on exam (though I hate being fake)

5.  Percussion  —  Not usually useful for anything except a) estimating liver size, b) for distended bladder in symptomatic pts, & c) abdominal resonance / tympany rarely for seeking subtle splenomegaly you can’t palpate.  Click here for Percussion Techniques.

• Special Maneuver for suspected ascites: Shifting Dullness (click for explanation, & for description of other stigmata of Cirrhosis)

6.  Punch Percussion for Hepatitis  —  If you suspect acute hepatitis, gently punch-percuss the liver over the lower right rib cage.  Compare it to the contralateral side.

• Significant tenderness on right (& none on left) suggests acute hepatitis.  A physician with early symptoms of Hep A once noted that when jogging, his liver hurt every time he stepped on the right foot!

7.  Palpation  —  The crux of the abdominal exam.  Begin with light palpation, moving around the abdomen, so patient gets used to your touch.  Then go deeper.

• If patient had previously designated an area of pain, save it for last.

8.  Distraction!!!  It’s essential to talk to patient while you palpate.  Ask about their family, sports, the weather, whatever [maybe not politics]

• NEVER inquire, “Does this hurt?”  Assess tenderness by patient’s facial expression, guarding, etc.

9.  If you find a tender area, keep palpating elsewhere, then return to it several times, doing your best to distract.

• Try hard to convince yourself there’s “no tenderness,” because serious abdominal disease will produce tenderness every time you palpate.
• If I’m able to re-palpate an area without patient reacting, I chart “No Tenderness,” regardless of the initial response.
• Especially important for children.

10.  Rebound Tenderness — assess it by percussing the abdomen, or wiggling the pelvis, or banging bottom of patient’s heels.  Peritonitis is NOT SUBTLE.

• Obdurator & Psoas Signs are performed by surgeon about to operate on a boardlike abdomen, for guidance what to seek on lap.  They’re not subtle ways to diagnose appendicitis.

11.  Carnett’s Sign  —  Very useful (though I never knew the eponym until recently).  Identifies tenderness due to abdominal wall conditions (e.g. muscle strain)

• Identify area of tenderness
• Then palpate it while patient flexes the abdomen (tries to sit up)
• If tenderness is greater during flexion than when lying relaxed, it’s the abdominal wall.  Patients are usually immediately convinced & relieved.

11a.  A recent patient had right flank pain, radiating toward groin but not to labia as with classical renal colic.  There was mild flank tenderness, no CVA tenderness, normal urinalysis.  Carnett’s sign was negative.  But tenderness was elicited (patient standing) with right lateral bend and left rotation of L-S Spine.  Diagnosis: muscle strain.

12.  Costovertebral Angle (CVA) Tenderness  —  Diagnosing pyelonephritis (kidney stones are very painful, but not tender)

• Punch-percussion of CVA should be very tender — patient screams, doesn’t simply say, “Yes, it hurts.”
• Should have unilateral flank tenderness as well, or I’d doubt the diagnosis

13.  Hepatomegaly  —  If you palpate a liver edge, don’t call it “enlarged” without percussing out the size (click for Percussion Techniques).  The liver may simply be low-lying, but normal in size.

14.  Splenomegaly  —  Begin palpating lightly in midline, working your way to the Left Costal Margin.  There’ve been cases of splenic rupture due to over-vigorous palpation by overeager clinicians.

• Still, you do need to palpate deeply under the costal margin before you can say “no splenomegaly”.  Feel for a spleen edge while patient inhales deeply, then palpate inward during deep expiration, and feel again during subsequent inspiration.
• If negative, repeat with patient lying on right side (more sensitive)

14.  DO NOT perform a Fecal Occult Blood Test (FOBT) during physical exam !!!  The FOBT is purely intended as a screen for colon cancer in patients >50 y.o., to be taken home & collected without anal manipulation.  Obtaining it during exam decreases specificity.

• I’ve seen clinicians perform FOBT’s on patients with diarrhea or epigastric pain — what do you do when a 25-yr.-old tests positive?  Send for colonoscopy??? [& get laughed at by G-I !!!]  Save it as a screen; nothing else

That’s it for the Abdomen, as well as Eye, HENT, Heart, and Lungs from prior postings.  Will conclude this topic with miscellaneous tips about remaining organ systems next time.