A.
APPROACH TO PATIENT / GENERAL GUIDELINES
Good morning, I’m Dr ______. May I know
1. Explain purpose & importance of examination; secure consent your name? I’m going to examine your
abdomen, is that okay with you?
2. Position the patient properly.
Drape and adequately expose the abdomen
3. Position himself on the right side of the patient.
Examiner fingers should be short
4. Proper sequence of examination
(inspection, auscultation, palpation/percussion)
INSPECTION
5. Abdominal circumference at level of umbilicus Pag at the level of the abdomen ang tingin,
Tape measure, measure mo yung sa umbilicus nya dun mo malalaman yung contour. Wag isang
tinginan lang ok na, take your time
6. Abdominal contour Patient’s abdominal circumference is
Tingnan mo sa baba _____ inches at the level of the umbilicus.
Abdomen is flat, symmetrical, without
abnormal bulging or masses. There are no
7. Symmetry/localized bulging visible scarring, lesions, superficial veins,
striae or discoloration upon inspection.
Umbilicus is inverted. No visible
pulsations or peristalsis noted.
8. Skin: color, discoloration, lesions, superficial veins
9. Umbilicus, appearance/lesions, discharge
10. Abdominal movements: visible peristalsis, pulsations
AUSCULTATION
11. Use diagphram to appreciate bowel sound & borborygmi on 4 quadrants
Place the diaphragm of your stethoscope lightly over the right lower
quadrant and listen for bowel sounds. If you don't hear any, continue Start listening for bowel sounds at the RLQ.
listening for 5 minutes within that quadrant. Then, listen to the right upper Memorize the info dun sa TECHNIQUE.
quadrant, the left upper quadrant, and the left lower quadrant.
12. Use bell & diagphram to appreciate on bruit on epigastric
RUQ, LUQ, LLQ, RLQ Bowel sound is ____ cycles per minute
upon auscultation.
No bruit heard over abdominal aortic
vessel, right and left renal arteries and
right and left iliac arteries.
13. Bowel sounds: describes intensity, how many per minute
14. Abdominal bruits, abdominal aorta, renal arteries & iliac arteries
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15. Abdominal friction rub over RUQ & LUQ
PALPATION
Abdomen is soft with no tenderness or rigidity. No superficial masses palpated. Liver, spleen and kidney are not palpable
17. Stand on right side of patient; Position the patient correctly
18.Ask patient if theres abdominal pain; Direction of palpation
A. Light palpation
19. Check technique
Parang hinihimas niyo lang siya ng madiin.
Light palpation Bawat press, tanungin kung masakit..
-useful in identifying: muscular resistance areas of tenderness
Procedure:
1) Inquire for the presence of abdominal pain Abdomen is soft with no tenderness or
Locate areas of discomfort by: rigidity. No superficial masses palpated.
-taking a rapid and deep inspiration
-coughing
-sucking in the abdomen Areas which are painful or with discomfort SHOULD BE
EXAMINE LAST.
2) Patient is in supine position, comfortable with knees slightly flex to relax the
abdomen.
3) Examiner stand on the right side of the patient.
Hand should be warm and finger nails short to avoid producing muscle contraction.
4) Place the entire palm with fingers extended and approximated on the surface of
the abdomen.
5) Press the fingertips gently into the abdomen to a depth of about 1cm.
6) Begin at the pubes and work upward to the
costal margins.
7) Move your hand gently from place to place
by raising it just off the skin and feel in all quadrants. Avoid sudden movement.
8) Watch the patient’s face for evidence of discomfort as you palpate.
9) Explain to the patient what you are doing and its necessity.
10) Distract patient if necessary w/ conversation or questions.
11) Ask pt to breath slowly through mouth
Ticklishness of the patient
-can limit your palpation of abdomen.
Ways to overcome:
1) Ask patient to perform self-palpation.
2) Place your hands over the patient’s fingers not quite touching the abdomen.
After a time, let your fingers drift slowly onto the abdomen while still resting primarily
on the patient’s fingers.
3) Use diaphragm of stethoscope as a palpating instrument as a starting point
20. Assess: Tenderness (Direct/Rebound) ; palpable mass
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B. Deep Palpation
21. Check technique 1. Left hand under patient (right side)
2. Right hand below subcostal margin,
Methods: fingers facing HEAD of patient.
A. Single Hand Palpation 3. Ask patient to inhale, sabay tulak ng left
same technique as light palpation, but push down 5-8 cms(2-3 inches). hand pataas.
1) Place palmar surface of right hand on the abdomen. 4. Normal – not palpable
2) Press more deeply using approximated fingers.
3) The finger pads should cause the abdominal wall to glide over the underlying With the deep palpation, there are no
structure to and fro in a range of 4-5 cm. masses found and is normal.
B. Reinforced Palpation or Double-Handed Palpation
-done when deep palpation is difficult as in:
obesity
muscle resistance is strong
suspect deep seated pathology
1) Press fingers of L hand upon distal pharyngeal joints of the Rthand during
palpation.
2) With 2 hands on top of each other, > top hands does the pushing
bottom hand is relaxed and concentrates on the sense of palpation.
C. Bimanual Palpation
place hand on each side of mass.
1) Bimanual Palpation of RUQ
-place your L hand behind the patient, parallel to & supporting the R 11th&
12thrib and adjacent soft tissues below.
-place your R hand on patient’s R abdomen, lateral to the rectus
muscle with your fingertips well below the lower border of liver dullness.
press R hand gently in and up with L hand lifting the back.
ask the patient to take a deep breath & during expiration pushed the R
hand into the abdomen gently.
repeat the maneuver several times & try to feel the liver edge as it comes
down to meet your fingertip during inspiration and as it goes up during
expiration.
if you feel it, lighten the pressure of your palpating hand slightly so that the
liver can slip under your finger pads.
feel the anterior surface of the liver. Note for the texture, tenderness &
masses.
2) Bimanual Palpation of LUQ
-stand at the R side of the supine patient.
-lay the palm of the hand on the abdominal wall in the LUQ and place the
tips of the approximated fingers just inferior to the rib margin in the L
anterior axillaryline.
place the palm of the L hand on the L midaxillary region of the thorax, with
the fingers curling posteriorlyto support the thoracic wall at the 11th&
12thribs.
ask the patient to inspire deeply and slowly through the mouth.
during inspiration, bring the 2 hands closer together by lifting the posterior
wall with the L hand, while firmly pushing the approximated fingers of the R
hand inward & upward behind the costal margin.
repeat the procedure.
22. Assess: Tenderness; palpable mass
C. Palpation of liver
23. Check technique 1. Left hand under patient (right side)
2. Right hand below subcostal margin,
24. Findings if palpable: How many fingerbreadth below RSCM fingers facing HEAD of patient.
Character of liver edge 3. Ask patient to inhale, sabay tulak ng left
Consistency hand pataas.
Tenderness 4. Normal – not palpable
LIVER Liver is not palable.
-usually not palpable in adult.
-maybe felt in some persons even
when no pathologic condition exist.
-on inspiration, it is palpable about 3 cm below the Rtcostal margin in
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MCL because respiratory excursion of diaphragm displace the liver edge
downward.
Technique:
1). One hand palpation
-Place your Rthand on abdomen, finger pointing toward the head and
extended so the tips rest on the RMCL.
-or place your Rthand parallel to the Rtsubcostalmargin.
-then press your Rthand gently but deep in & up.
-have patient breathe regularly a few times & then take a deep breath.
-try to feel the liver edge
-if liver is felt, it should be firm, smooth & non-tender.
-note for: contour, surface, tenderness, nodularity, size ( fingerbreathor
in cm below RSCM)
2) Hooking technique
-hook your fingers over the Rtcostal margin below the border of liver
dullness.
-stand on the patient’s right side facing his or her feet.
-press in and up toward the costal margin with your fingers and ask patient
to take a deep breath.
-try to feel the liver edge as it descends to meet your fingers.
-very helpful in obese patients.
Liver tenderness
-ndicates: distention of hepatic capsule abscess
Liver size
-estimation of size should be based on both palpation and percussion
(LIVER SPAN)
-a palpable liver does not necessarily indicate HEPATOMEGALY.
Example: downward displacement of liver by a low diaphragm in patient with COPD.
Palpation of liver edge
is totally inaccurate marker of hepatomegaly.
its significance is in identification of the consistency of lower liver edge
which may give you a clue as to the specific liver disease
D. Palpation of Spleen
25. Check technique
1. Left hand under patient (left side)
2. Right hand below subcostal margin,
26. Findings if palpable: How many fingerbreath below LSCM fingers facing your supporting (left) hand
Character of liver edge 3. Ask patient to inhale, sabay tulak ng left
Consistency hand pataas.
Tenderness 4. Normal – not palpable
Spleen Spleen is not palpable
-when it enlarges, it expands anteriorly, downward and medially replacing
the tymphany( stomach and colon)
Dullness
-usually not palpable in adult
-if its palpable, probably splenomegaly
A. Supine Position
1) While standing on patient’s Rtside, reach across with your L hand and
place beneath patient over L costovertebral angle.
2) Press upward with that hand to lift the spleen anteriorlytoward the
abdominal wall.
3) Place the palmarsurface of your Rthand w/fingers extended on the patient’s
abdomen below the L costal margin.
4) Press your fingertips inward toward the spleen as you ask the patient to
take a deep breath.
5) Try to feel the edge of the spleen as it moves downward toward your
fingers.
6) Be sure to palpate with your fingers below the costal margin so that you will
not miss the lower edge of an enlarged spleen.
7) Be gentle in palpation to avoid rupturing an enlarged spleen.
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Note for:
tenderness
>splenic contour and consistency
measure distance between spleen’s lowest point and LSCM
B. Repeat palpation while patient is lying on Rtside with hips and knees
flexed.
This position bring spleen forward and to the Rtinto palpable position.
1) Press inward with your L hand to assist gravity in bringing the spleen
forward and to the Rt.
2) Press inward with fingertips of your Rthand and feel for the edge of the
spleen.
C.Hooking technique (Middleton’s Method)
Patient lies with his L fist beneath the L thorax.
Examiner stands on patient’s L side facing the patient’s feet and curl your
fingers over the L costal margin so that your fingertips are pointing
cephaladunder the ribs. Feel for the splenicedge during a deep inspiration.
Spleen consistency
Acute infection –spleen may become moderately enlarged, soft with blunted edges.
Chronic disorder –spleen may be firm or hard and sharp edges.
Spleenictenderness
-splenomegalyis non-tender except when peritoneum is inflammedfrom:> infection
or > infarction
E. Palpation of Kidneys
Right Kidney 1. Left hand under patient, level of
27. Check technique umbilicus 2. Right hand beside
28. Findings on palpation of Right kidney umbilicus 3. Normal – not palpable\
Kidneys
-not usually palpable since they are located in retroperitoneal area.
Both right and left kidneys are nott palpable
Technique :
A. Palpation of right kidney
> a normal Rtkidney may be palpable espin thin, well-relaxed women.
> 1-2 cm lower than the left.
> if palpable, it is smooth, firm and non-tender.
> must be distinguished from the palpable liver:
1) liver edge is sharper whereas kidney is more rounded.
2) liver extends more medially & laterally
3) liver cannot be captured
Technique:
1) Stand on the patient’s right side, placing your left hand under the patient’s right
flank and your right hand at the right costal margin.
Perform the same maneuver as you did for the left kidney.
2) To capture the right kidney, stay on the right side of the patient. Use your left
hand to lift from back and your right hand to feel deep in left upper quadrant.
Proceed as you did in left kidney.
Left Kidney
29. Check technique
30. Findings on palpation of left kidney
Palpation of left kidney
>normal L kidney rarely palpable
1) Standing on the patient’s Rtside, reach across w/ your L hand as you did in
spleen palpation & place it over the L flank. Place your Rthand at patient’s L costal
margin.
-Have patient take a deep breath & then elevate the L flank with your L hand &
palpate deeply with your Rthand.
-Try to feel the lower pole of the kidney with your fingertips as the patient inhales.
2) Capture technique
-move to the patient’s L side, place the L hand over the patient’s L flank & the
Rthand at L costal margin.
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-ask patient to take a deep breath & at the height of inspiration, press the fingers at
your 2 hands together to capture the kidney between 2 fingers.
-ask patient to breath out, slowly release thepressure & feel for the kidney to slip
between the fingers.
-this is not painful, although patient may feelthe capture & release.
F. Palpation of abdominal aorta
31. Check technique
32. Findings - width of abdominal aorta
- direction of aortic pulsation
Abdominal Aorta Palpation
-Aortic pulse may be felt ( esp. thin adult) and should be in anterior direction.
-The ease of feeling aortic pulsation varies w/: > thickness of abdominal wall >
anteroposteriordiameter of the abdomen.
Technique :
1) In supine position palpate deeply slightly to the left of the midline and feel for
aortic pulsation and if prominent, determine the direction of pulsation.
2) Alternately, place palmarsurface of your hands with fingers extended on the
midline.
-Press the fingers deeply inward on each side of the aorta and feel for the pulsation
and try to assess the width of the aorta.
Normal aorta is not more than 3 cm wide (excluding the thickness of abdominal
wall).
In thin individuals, you can use your hand, placing the thumb over one side of aorta
and the fingers on the other side.
PERCUSSION
Abdomen exhibits general tympanism. Liver span is within normal limits at 9 cm. Spleen dullness is absent at Traube’s space.
A. General Tymphanism of abdomen
33. Technique: Indirect method of percussion
Percussion
Method: Indirect or Mediate
Assess:
1) Size and density of abdominal organs.
2) Amount and distribution of gas/air.
3) Presence of fluid and Fluid-filled or solid masses.
A. Percussion in all four quadrants
-Tymphaniticpredominantly because of air present in stomach and intestine.
-Dullness over solid organs and presence of solid masses.
Distended bladder –dullness on suprapubicarea.
Splenomegaly–dullness on LUQ
Technique:
1) Horizontal
2)Radial –from the umbilicus
3) Vertical
34. Findings
B. Liver Dullness
35. Technique 1. Adjust drape, to nipple line
-Determine lower border of liver 2. Percuss from RMCL, slightly below
-Determine upper border of liver umbilicus. Pag nagshift to dullness, ibalik
niyo muna sa tympanitic portion to be sure
B. Liver span (parang double check kung nag dull nab a
-more accurate in estimation of liver size. talaga) if sure na, mark area. WARN THE
1) Begin liver percussion at RMCL over an area of tymphanyand proceed to an area PATIENT, nagugulat sila pag bigla niyo sila
of dullness. sinusulatan/tinutusok ng ballpen.
2) Percussupward along MCL to determine the lower border of the liver.
> the area of liver dullness is usually heard at thecostal margin or slightly below it.
> a lower liver border that is >2-3cm below the costal margin may indicate:
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Hepatomegaly 3. Percuss from slightly below nipple line,
Downward displacement of diagphram RMCL. The same, idouble check kung
nagdull ba talaga. Mark
3) Percusson RMCL over area of lung resonance to determine the upper border of 4. Measure using tape measure. Normal liver
the liver continue downward until the percussion tone changes to one of dullness span is 6 to 12 cm.
which marks the upper border of the liver.
Upper border usually begins at 5thto 7thICS.
Dullness below 7thICS indicate:
Downward displacement
Liver atrophy-cirrhosis
Dullness extending above 5thICS suggest:
Upward displacement from abdominal fluid or masses.
4) Measure the distance between the marks to estimate the vertical span of the liver
.
Normally:
midsternalline : 4-8 cm
midclavicularline: 6-12 cm
Error in estimation of liver span:
-right pleural effusion
-right lung consolidation
-gas in the colon
36. Findings
C. Splenic Dullness - Traube's space
37. Delineate the border of Traube's space 1. Boundaries: superior – left 6 th rib Lateral
Percussion of Traube's space – left midaxillary line Inferior – left costal
margin
38. Findings 2. Percuss – normal is tympanitic. If dull =
splenomegaly
D. Fist Percussion
39. Liver Fist Percussion
- technique
- findings
D. Fist percussion of the liver
> use to check for liver tenderness when the liver is not palpable.
Methods:
1) place the palmarsurface of one hand over the lower right rib cage.
2) strike your hand with the ulnarsurface of the fist of your other hand.
Normally :
liver is not tender to percussion.
(+) tenderness
> hepatomegalydue to: infection abscess malignancy
40. Spleenic Fist Percussion
- technique
- findings
C. Splenicdullness
4 Methods :
1) Nixon’s Method
2) Castell’sMethod
3) Percussion of Traube’sspace
4) Percussion along midaxillaryline
1) Nixon’s technique
-position patient in right lateral decubitus(allows the spleen to lie above the stomach
and colon ).
-percussion is initiated at lower level of lung resonance in approximately the
posterior axillaryline and curved down obliquely on perpendicular line toward the
lowest and anterior costal margin.
-normally the upper border of dullness is 6-8 cm above the costal margin.
-dullness over 8 cm is indicative of splenomegaly.
2) Castell’stechnique
-in supine position, percussthe lowest intercostalspace (8th-9th) along the left
anterior axillaryline.
-patient is instructed to breathe in deeply and then to exhale. -Percussion is carried
out both during inspiration and expiration.
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.
Castell’ s Technique
-normally, resonant at 8thand 9thICS along left anterior axillaryline both on
inspiration &expiration.
(+) percussion sign : dullnesson full inspiration at 8thand 9thICS
3) Percussion of Traube’ssemilunarspace which is tymphaniticbecause of air
bubble in the stomach.
Traube’sspace –an area bordered by :
superiorly : left 6thrib
laterally : left midaxillaryline
inferiorly : left costal margin
Obliteration of Traube’sspace by dullness with splenomegaly.
4) Percussionalong the left midaxillaryline from the 9thto the 11thICS –
spleenicdullness
-begin at areas of lung resonance
E. Costovertebral angle tenderness
41. Right kidney
- deleneate the right costovertebral angle 1. Place hands below 12th rib sa likod
- technique malapit sa spine. (costovertebral angle) 2.
- findings Strike with ulnar side of other hand. 3.
Repeat sa other side 4. Normal – walang
(Tenderness, Kidney punch ) pain.
Methods:
1) patient in sitting position with examiner standing behind.
2) place the palm of one hand over the costovertebralangle.
3) strike that hand with the ulnarsurface of the fist of your other hand.
4) direct percussion with fist over the CVA may also be used.
5) the patient perceive the blow as a thud, not pain nor tenderness.
6) repeat the maneuver over the other kidney.
(+) if there is tenderness
Indicates :
-inflammation of the kidneys
-any cause of hydronephrosis
-inflammation of paranephricregion
-musculoskeletal disorder
42. Left kidney
- deleneate the left costovertebral angle
- technique
- findings
F. Special Examinations
Special tests sample report (banggitin kung para saan yung special test na nirereport mo): Negative result for Murphy’s sign, no
acute cholecystitis. Negative results for Psoas, Obturator, Markel’s and Rovsing’s sign, no acute appendicitis. Negative results for
fluid wave and shifting dullness, no ascites. No costovertebral angle tenderness, no acute pyelonephritis.
A. Test for Ascites
43. Fluid Wave
a. Technique 1. ask pt to put hand in middle of abdomen
b. Findings 2. 1 hand should be tapping, yung isa
pinapakiramdaman kung may fluid wave. 3.
Normal – wala dapat maramdaman. (para
malaman niyo kung ano pakiramdam ng fluid
wave, magtap kayo ng walang kamay sa
gitna ng abdomen =D)
44. Shifting Dullness 1. pt is supine. Percuss from abdomen
a. Technique palateral. Mark the area kung saan magiging
b. Findings DULL ang sound. 2. pt in right side lying
(facing you) percuss from the top. 3. Positive
pag nalipat yung dullness
B. Test for Acute Appendicitis
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45. Mc Burney's sign
a. Technique
b. Findings
> (+) direct tenderness at the Right iliac or McBurney’spoint.
46. Blumberg's sign
a. Technique
b. Finding
> (+) rebound tenderness at the right iliac region
47. Rovsing's sign 1. press LLQ 2. (+) result – pain at RLQ pag
a. Technique binitawan mo na yung LLQ
b. Findings
> pain felt by the patient in RLQ w/pressure & release of pressure on the LLQ.
48. Markle's sign 1. let patient stand on tiptoes tapos biglang
a. Technique bagsak. 2. (+) result = pain
b. Findings
> pain felt on the RLQ upon jarring the body either by: -coughing
-standing on toes then suddenly drop heels on the floor
49. Psoa's sign 1. Flex the thigh while supine. 2. Positive sign
a. Technique – pain at RLQ
b. Findings
1) Ask the patient to lie supine & place your hand over the lower thigh.
Then raise the leg, flexing at the hip, while push downward against the leg2)
Position the patient on the left side & ask that the right leg be raised from the hip
while you press downward against it.
3) Ask patient to hyperextend the leg by drawing it backward while patient is lying on
the right side.
Results (+): patient will experience pain on RLQ.
Inflamed appendix may causeirritation of the lateral iliopsoasmuscle.
50. Obturator sign 1. Internally rotate the thigh 2. Positive sign
a. Technique – pain at RLQ
b. Findings
1) Patient in supine position flex the right leg at the hip and knee to 90 degrees
2) Hold the leg just above the knee, grasp the ankle, and rotate the leg laterally and
medially.
Results (+): pain at RLQ
Inflamed appendix causes irritation of the obturatormuscle and when stretch it will
cause pain.
C. Test for Acute Cholecystitis
51. Murphy's sign
a. Technique
b. Findings
1) Place the fingers of your right hand under the right costal margin.
2) Ask the patient to take a deep breath while gliding the examining fingers upward.
3) Watch the patient’s breathing and note the degree of tenderness.
Results (+): Inspiratoryarrest secondary to sharp increase in tenderness as the
descending liver pushes the inflamed GB onto the examiner’s fingertips.
52. Boa's sign
a. Technique
b. Findings
A light touch(hyperesthesia) on the right costophrenicangle elicit an exquisite
tenderness. This is also the site of referred pain for gallbladder.
References: ppt ni doc Cortez, and (GUIDE TO CLINICAL MEDICINE I: PRACTICALS Dok T - The Unreliable Sources ABDOMEN)
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