Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 13. Abdomen

EQUIPMENT

image Stethoscope

image Centimeter ruler or tape measure

image Marking pen

EXAMINATION

Have patient in the supine position to start the examination. Approach the patient from the right side.

TECHNIQUE

FINDINGS

Inspect abdomen in all four quadrants (see box on p. 151)

imageSkin color/characteristics

EXPECTED:Usual color variations, such as paleness or tanning lines. Fine venous network (venous return toward head above umbilicus, toward feet below umbilicus).

UNEXPECTED:Generalized color changes, such as jaundice or cyanosis. Glistening taut appearance. Bluish periumbilical discoloration, bruises, other localized discoloration. Striae, lesions or nodules, a pearl-like enlarged umbilical node, scars.

imageContour/symmetry

Begin seated to patient’s right to enhance shadows and contouring. Inspect while patient breathes comfortably and while patient holds a deep breath. Assess symmetry, first seated at patient’s side, then standing behind patient’s head.

EXPECTED:Flat, rounded, or scaphoid. Contralateral areas symmetric. Maximum height of convexity at umbilicus. Abdomen remains smooth and symmetric while patient holds breath.
UNEXPECTED:Umbilicus displaced upward, downward, or laterally or is inflamed, swollen, or bulging. Any distention (symmetric or asymmetric), bulges, or masses while breathing comfortably or holding breath.

imageSurface motion

EXPECTED:Smooth, even motion with respiration. Females mostly costal; males mostly abdominal. Pulsations in upper midline in thin adults.

UNEXPECTED:Limited motion with respiration in adult males. Rippling movement (peristalsis) or marked pulsations.

Anatomic Correlates of the Four Quadrants of the Abdomen

Right Upper Quadrant (RUQ)

Liver and gallbladder

Pylorus

Duodenum

Head of pancreas

Right adrenal gland

Portion of right kidney

Hepatic flexure of colon

Portions of ascending and transverse colon

Right Lower Quadrant (RLQ)

Lower pole of right kidney

Cecum and appendix

Portion of ascending colon

Bladder (if distended)

Ovary and salpinx

Uterus (if enlarged)

Right spermatic cord

Right ureter

Left Upper Quadrant (LUQ)

Left lobe of liver

Spleen

Stomach

Body of pancreas

Left adrenal gland

Portion of left kidney

Splenic flexure of colon

Portions of transverse and descending colon

Left Lower Quadrant (LLQ)

Lower pole of left kidney

Sigmoid colon

Portion of descending colon

Bladder (if distended)

Ovary and salpinx

Uterus (if enlarged)

Left spermatic cord

Left ureter

Inspect abdominal muscles as patient raises head

 

EXPECTED:No masses or protrusions.

UNEXPECTED:Masses, protrusion of the umbilicus and other hernia signs, or muscle separation.

Auscultate with stethoscope diaphragm

imageFrequency and character of bowel sounds

Warm stethoscope diaphragm, and hold with light pressure.

May auscultate at a single site because bowel sounds generalize, but auscultate in all quadrants if you have reason to be concerned.

EXPECTED:Five to 35 irregular clicks and gurgles per minute. Borborygmi, or increased sounds, due to hunger.

UNEXPECTED:Increased sounds unrelated to hunger, high-pitched tinkling sounds, or decreased or absent sounds after 5 minutes of listening (may be associated with abdominal pain and rigidity).

imageLiver and spleen

EXPECTED:Silent.

UNEXPECTED:Friction rubs.

Auscultate with stethoscope bell

imageVascular sounds

Listen with stethoscope bell in epigastric region, over aorta, and over renal, iliac, and femoral arteries.

EXPECTED:No bruits, venous hum, or friction rubs.

UNEXPECTED:Bruits in aortic, renal, iliac, or femoral arteries.

From Thompson and Wilson, 1996.

image

imageEpigastric region and around umbilicus

EXPECTED:No venous hum.

UNEXPECTED:Venous hum.

Percussion Notes of the Abdomen

Note

Description

Location

Tympany

Musical note of higher pitch than resonance

Over air-filled viscera

Hyperresonance

Pitch lies between tympany and resonance

Base of left lung

Resonance

Sustained note of moderate pitch

Over lung tissue and sometimes over abdomen

Dullness

Short, high-pitched note with little resonance

Over solid organs adjacent to air-filled structures

Modified from AH Robins Co.

TECHNIQUE

FINDINGS

Percuss abdomen

Note: Percussion can be done independently or concurrently with palpation.

imageTone

Percuss in all quadrants.

EXPECTED:Tympany predominant. Dullness over organs and solid masses. Dullness in suprapubic area from distended bladder. See table on p. 153 for percussion notes.

UNEXPECTED:Dullness predominant.

imageLiver span

To determine lower liver border, percuss upward at right midclavicular line, as shown in figure below, and mark with a pen where tympany changes to dullness. To determine upper liver border, percuss downward at right midclavicular line from an area of resonance, and mark change to dullness. Measure the distance between marks to estimate vertical span.

EXPECTED:Lower border usually begins at or slightly below costal margin. Upper border usually begins at fifth to seventh intercostal space. Span generally ranges from 6 to 12 cm in adults.

UNEXPECTED:Lower liver border more than 2 to 3 cm below costal margin. Upper liver border above the fifth or below the seventh intercostal space. Span less than 6 cm or greater than 12 cm.

image

imageSpleen

Percuss just posterior to midaxillary line on left, beginning at areas of lung resonance and moving in several directions. Percuss lowest intercostal space in left anterior axillary line before and after patient takes deep breath.

EXPECTED:Small area of dullness from sixth to tenth rib. Tympany before and after deep breath.

UNEXPECTED:Large area of dullness (check for full stomach or feces-filled intestine). Tone change from tympany to dullness with inspiration.

imageStomach

Percuss in area of left lower anterior rib cage and left epigastric region.

EXPECTED:Tympany of gastric air bubble (lower than intestine tympany).

UNEXPECTED:Dullness.

Lightly palpate abdomen

Stand at patient’s right side. Systematically palpate all quadrants, avoiding areas previously identified as problem spots. With palmar surface of fingers, depress abdominal wall up to 1 cm with light, even circular motion.

EXPECTED:Abdomen smooth with consistent softness. Possible tension from palpating too deeply, cold hands, or ticklishness.

UNEXPECTED:Muscular tension or resistance, tenderness, or masses. If resistance is present, place pillow under patient’s knees, and ask patient to breathe slowly through mouth. Feel for relaxation of rectus abdominis muscles on expiration. Continuing tension signals involuntary response to abdominal rigidity.

Palpate abdomen with moderate pressure

Using same hand position as above, palpate all quadrants again, this time with moderate pressure.

EXPECTED:Soft, nontender

UNEXPECTED:Tenderness.

Deeply palpate abdomen

With same hand position as above, repeat palpation in all quadrants, pressing deeply and evenly into abdominal wall. Move fingers back and forth over abdominal contents. Use bimanual technique—exerting pressure with top hand and concentrating on sensation with bottom hand, as shown in figure below—if obesity or muscular resistance makes deep palpation difficult. To help determine whether masses are superficial or intraabdominal, have patient lift head from examining table to contract abdominal muscles and obscure intraabdominal masses.

EXPECTED:Possible sensation of abdominal wall sliding back and forth. Possible awareness of borders of rectus abdominis muscles, aorta, and portions of colon. Possible tenderness over cecum, sigmoid colon, and aorta and in midline near xiphoid process.

UNEXPECTED:Bulges, masses, tenderness unrelated to deep palpation of cecum, sigmoid colon, aorta, xiphoid process. Note location, size, shape, consistency, tenderness, pulsation, mobility, movement (with respiration) of any masses.

image

imageUmbilical ring and umbilicus

Palpate umbilical ring and around umbilicus. Note whether ring is incomplete or soft in center.

EXPECTED:Umbilical ring circular and free of irregularities. Umbilicus either slightly inverted or everted.

UNEXPECTED:Bulges, nodules, granulation. Protruding umbilicus.

imageLiver

Place left hand under patient at eleventh and twelfth ribs, lifting to elevate liver toward abdominal wall. Place right hand on abdomen, fingers extended toward head with tips on right midclavicular line below level of liver dullness, as shown in figure at right. Alternatively, place right hand parallel to right costal margin, as shown in figure at right, below. Press right hand gently but deeply in and up. Ask patient to breathe comfortably a few times and then take a deep breath. Feel for liver edge as diaphragm pushes it down. If palpable, repeat maneuver medially and laterally to costal margin.

EXPECTED:Usually liver is not palpable. If felt, liver edge should be firm, smooth, even.

UNEXPECTED:Tenderness, nodules, or irregularity.

image

image

imageGallbladder

Palpate below liver margin at lateral border of rectus abdominis muscle.

EXPECTED:Gallbladder not palpable.

UNEXPECTED:Palpable, tender or nontender. If tender (possible cholecystitis), palpate deeply during inspiration and observe for pain (Murphy sign).

imageSpleen

Reach across patient with left hand, place it beneath patient over left costovertebral angle, and lift spleen anteriorly toward abdominal wall. As shown in figure at right, place right hand on abdomen below left costal margin and—using findings from percussion—gently press fingertips inward toward spleen while asking patient to take a deep breath. Feel for spleen as it moves downward toward fingers.

Repeat with patient lying on right side, as shown in figure at right below, with hips and knees flexed. Press inward with left hand while using fingertips of right hand to feel edge of spleen.

EXPECTED:Spleen usually not palpable by either method.

UNEXPECTED:Palpable spleen.

image

image

imageLeft kidney

Standing on patient’s right, reach across with left hand, and place over left flank; then place right hand at patient’s left costal margin. Ask patient to inhale deeply, while you elevate left flank and palpate deeply with right hand.

EXPECTED:Left kidney usually not palpable.

UNEXPECTED:Tenderness.

From Thompson and Wilson, 1996.

image

image Right kidney

Standing on patient’s right, place left hand under right flank, then place right hand at patient’s right costal margin. Ask patient to inhale deeply while you elevate right flank and palpate deeply with right hand.

EXPECTED:If palpable, right kidney should be smooth and firm with rounded edges.

UNEXPECTED:Tenderness.

image

image Aorta

Palpate deeply slightly to left of midline, and feel for aortic pulsation. As an alternative technique, place palmar surface of hands with fingers extended on midline; press fingers deeply inward on each side of aorta, and feel for pulsation. For thin patients, use one hand, placing thumb and fingers on either side of aorta.

EXPECTED:Pulsation anterior in direction.

UNEXPECTED:Prominent lateral pulsation.

image

image Urinary bladder

Percuss distended bladder to help determine outline, then palpate.

EXPECTED:Ordinarily not palpable unless distended with urine. If distended, bladder should be smooth, round, and tense and on percussion will elicit lower note than surrounding air-filled intestines.

UNEXPECTED:Palpable when not distended with urine.

With patient sitting, percuss costovertebral angles

Stand behind patient. Right side: Place left hand over right costovertebral angle and strike with ulnar surface of right fist. Left side: Repeat with hands reversed.

EXPECTED:No tenderness.

UNEXPECTED:Kidney tenderness or pain.

Pain assessment

Keep eyes on patient’s face while examining abdomen. To help characterize pain, have patient cough, take a deep breath, jump, or walk. Ask whether patient is hungry.

UNEXPECTED:Unwillingness to move, nausea, vomiting, areas of localized tenderness. Lack of hunger. See box and table on p. 161.

Iliopsoas muscle test

Use test for suspected appendicitis. With patient supine, place hand over right lower thigh. Ask patient to raise leg, flexing at hip, while you push downward.

UNEXPECTED:Lower quadrant pain.

image

Obturator muscle test

Use test for suspected ruptured appendix or pelvic abscess. With patient supine, ask patient to flex right leg at hip and bend knee to 90 degrees. Hold leg just above knee, grasp ankle, and rotate leg laterally and medially, as shown in figure at right.

UNEXPECTED:Pain in hypogastric region.

image

Modified from Judge et al, 1988

Some Causes of Pain Perceived in Anatomic Regions

Right Upper Quadrant

Duodenal ulcer

Hepatitis

Hepatomegaly

Lower lobe pneumonia

Cholecystitis

Right Lower Quadrant

Appendicitis

Salpingitis

Ovarian cyst

Tubo-ovarian abscess

Ruptured ectopic pregnancy

Renal/ureteral stone

Strangulated hernia

Meckel diverticulitis

Regional ileitis

Perforated cecum

Periumbilical

Intestinal obstruction

Acute pancreatitis

Early appendicitis

Mesenteric thrombosis

Aortic aneurysm

Diverticulitis

Left Upper Quadrant

Ruptured spleen

Gastric ulcer

Aortic aneurysm

Perforated colon

Lower lobe pneumonia

Left Lower Quadrant

Sigmoid diverticulitis

Salpingitis

Ovarian cyst

Ruptured ectopic pregnancy

Tubo-ovarian abscess

Renal/ureteral stone

Strangulated hernia

Perforated colon

Regional ileitis

Ulcerative colitis

Quality and Onset of Abdominal Pain

Characteristic

Possible Related Condition

Burning

Peptic ulcer

Cramping

Biliary colic, gastroenteritis

Colic

Appendicitis with impacted feces; renal stone

Aching

Appendiceal irritation

Knifelike

Pancreatitis

Ripping, tearing

Aortic dissection

Gradual onset

Infection

Sudden onset

Duodenal ulcer, acute pancreatitis, obstruction, perforation

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Hiatal hernia with esophagitis

Subjective Data:Epigastric pain and/or heartburn that worsens with lying down and is relieved by sitting up or antacids; water brash (mouth fills with fluid); dysphagia; sudden onset of vomiting, pain, complete dysphagia are symptoms of hernia incarceration.

Objective Data:With severe disease may have erythema of the posterior pharynx and edematous vocal cords.

Gastroesophageal reflux disease (GERD)

Subjective Data:Heartburn or acid indigestion (burning chest pain, located behind breastbone that moves up toward the neck and throat); sour taste of acid in the back of the throat, or hoarseness; symptoms in infants and children include back arching or fussiness with feeding, regurgitation, and vomiting; can precipitate acute asthma exacerbation, can cause respiratory problems from aspiration and can lead to esophageal bleeding.

 

Objective Data:With severe disease may have erythema of the posterior pharynx and edematous vocal cords.

Duodenal ulcer

Subjective Data:Localized epigastric pain that occurs when the stomach is empty and is relieved with food or antacids; hematemesis, melena, dizziness, syncope.

 

Objective Data:Anterior wall ulcers may produce tenderness on palpation of the abdomen; with significant upper gastrointestinal bleeding may have decreased blood pressure, increased pulse rate, and decreased hematocrit level; signs of an acute abdomen could indicate perforation of duodenum, a life-threatening event.

Acute diarrhea

Subjective Data:Abrupt onset, lasts less than 2 weeks; abdominal pain, diarrhea, nausea, vomiting, fever, tenesmus; if symptoms occur in two or more persons following ingestion of the same food, suspect food poisoning.

 

Objective Data:Diffuse abdominal tenderness; can mimic peritoneal inflammation with right lower quadrant pain or guarding; when severe may develop moderate to severe dehydration (decreased blood pressure, increased heart rate).

Crohn’s disease

Subjective Data:Chronic diarrhea (can be bloody) with malabsorption, cramping characterized by unpredictable flares and remissions.

Objective Data:Abdominal mass may be palpated from thickened or inflamed bowel; perianal skin tags, fistulae, and abscess formation; extraintestinal findings include arthritis of large joints, erythema nodosum, pyoderma gangrenosum.

Ulcerative colitis

Subjective Data:Bloody, frequent (up to 20 to 30 stools per day), watery diarrhea; mild to severe symptoms based on degree of colon involvement; weight loss, fatigue, general debilitation.

Objective Data:Generally do not have fistulae or perianal disease; cholestatic pattern of elevated transaminases suggests sclerosing cholangitis.

Irritable bowel syndrome (IBS)

Subjective Data:Cluster of symptoms consisting of abdominal pain, bloating, constipation and diarrhea; some patients have alternating diarrhea and constipation; mucus may be present around or within the stool.

Objective Data:Generally unremarkable exam.

Colon cancer

Subjective Data:May have abdominal pain, gross blood in stool, but more often presents with occult blood in stool on fecal occult blood test (FOBT); may have change in frequency or character of stool.

Objective Data:With progressive disease may have palpable mass in right or left lower quadrant; rectal mass may be palpable on digital rectal examination.

Hepatitis

Subjective Data:Some asymptomatic; others experience jaundice, anorexia, abdominal pain, clay-colored stools, tea-colored urine, fatigue.

Objective Data:Abnormal liver function tests; jaundice; hepatomegaly.

Cirrhosis

Subjective Data:Some asymptomatic; others experience jaundice, anorexia, abdominal pain, clay-colored stools, tea-colored urine, fatigue; may report prominent abdominal vasculature, cutaneous spider angiomas, hematemesis, abdominal fullness.

Objective Data:Abnormal liver function tests; jaundice; initially with firm, nontender enlarged liver; in severe disease liver size decreases, portal hypertension and esophageal varices may develop, and muscle wasting and nutritional deficiencies may occur.

Cholecystitis

Subjective Data:Acute: Right upper quadrant pain with radiation around midtorso to right scapular region; pain is abrupt and severe, lasting 2 to 4 hours; may have fever, jaundice, anorexia. Chronic: Repeated acute attacks; fat intolerance, flatulence, nausea, anorexia, nonspecific abdominal pain.

Objective Data:Marked tenderness in the right upper quadrant (RUQ) or epigastrium; involuntary guarding or rebound tenderness; some with full palpable gallbladder in RUQ.

Chronic pancreatitis

Subjective Data:Unremitting abdominal pain, weight loss, steatorrhea, glucose intolerance.

Objective Data:Diffuse abdominal tenderness to palpation; involuntary guarding and abdominal distention can occur; elevated pancreatic enzymes (amylase and lipase); may develop pseudocyst formation.

Pyelonephritis

Subjective Data:Flank pain, dysuria, fever; may have rigors, urinary frequency, urgency and hematuria.

Objective Data:Ill appearing with costovertebral angle (CVA) tenderness; pyuria and bacteria.

Renal calculi

Subjective Data:Fever, dysuria, hematuria; severe cramping and flank pain with nausea and vomiting; as the stone passes pain typically moves from flank to groin to scrotal or labial area.

 

Objective Data:Ill appearing with severe cramping pain; may have CVA tenderness or abdominal tenderness on palpation; microscopic hematuria.

Appendicitis

Subjective Data:Initially periumbilical or epigastric pain; colicky; later becomes localized to right lower quadrant (RLQ); anorexia, nausea, or vomiting after onset of pain; low-grade fever.

Objective Data:Guarding, tenderness, positive iliopsoas and/or obturator signs, RLQ pain on palpation (McBurney’s sign).

Abdominal Signs Associated with Common Abnormalities

Sign

Description

Associated Conditions

Aaron

Pain or distress occurs in the area of patient’s heart or stomach on palpation of McBurney’s point

Appendicitis

Ballance

Fixed dullness to percussion in left flank and dullness in right flank that disappear on change of position

Peritoneal irritation

Blumberg

Rebound tenderness

Peritoneal irritation, appendicitis

Cullen

Ecchymosis around umbilicus

Hemoperitoneum, pancreatitis, ectopic pregnancy

Dance

Absence of bowel sounds in right lower quadrant

Intussusception

Grey Turner

Ecchymosis of flanks

Hemoperitoneum, pancreatitis

Kehr

Abdominal pain radiating to left shoulder

Spleen rupture, renal calculi, ectopic pregnancy

Markle (heel jar)

Patient stands with straightened knees, then raises up on toes, relaxes, and allows heels to hit floor, thus jarring body; action will cause abdominal pain if positive

Peritoneal irritation, appendicitis

McBurney

Rebound tenderness and sharp pain when McBurney’s point is palpated (two thirds the distance from the umbilicus to the anterior superior iliac spine)

Appendicitis

Murphy

Abrupt cessation of inspiration on palpation of gallbladder

Cholecystitis

Romberg-Howship

Pain down medial aspect of thigh to knees

Strangulated obturator hernia

Rovsing

Right lower quadrant pain intensified by left lower quadrant abdominal palpation

Peritoneal irritation, appendicitis

Differential Diagnosis: Common Conditions Producing Acute Abdominal Pain

Condition

Usual Pain Characteristics

Possible Associated Findings

Appendicitis

Initially periumbilical or epigastric; colicky; later becomes localized to RLQ, often at McBurney’s point

Guarding, tenderness; + iliopsoas and + obturator tests, RLQ skin hyperesthesia; anorexia, nausea, or vomiting after onset of pain; low-grade fever; + Aaron, Rovsing, Markle, and McBurney signs*

Peritonitis

Onset sudden or gradual; pain generalized or localized, dull or severe and unrelenting; guarding; pain on deep inspiration

Shallow respiration; + Blumberg, Markle, and Ballance signs; reduced bowel sounds, nausea and vomiting; + obturator and iliopsoas tests

Cholecystitis

Severe, unrelenting RUQ or epigastric pain; may be referred to right subscapular area

RUQ tenderness and rigidity, + Murphy sign, palpable gallbladder, anorexia, vomiting, fever, possible jaundice

Pancreatitis

Dramatic, sudden, excruciating LUQ, epigastric, or umbilical pain; may be present in one or both flanks; may be referred to left shoulder

Epigastric tenderness, vomiting, fever, shock; + Grey Turner sign; + Cullen sign; both signs may occur 2-3 days after onset

Salpingitis

Lower quadrant, worse on left

Nausea, vomiting, fever, suprapubic tenderness, rigid abdomen, pain on pelvic examination

Pelvic inflammatory disease

Lower quadrant, increases with activity

Tender adnexa and cervix, cervical discharge, dyspareunia

Diverticulitis

Epigastric, radiating down left side of abdomen especially after eating; may be referred to back

Flatulence, borborygmi, diarrhea, dysuria, tenderness on palpation

Perforated gastric or duodenal ulcer

Abrupt RUQ; may be referred to shoulders

Abdominal free air and distention with increased resonance over liver; tenderness in epigastrium or RUQ; rigid abdominal wall, rebound tenderness

Intestinal obstruction

Abrupt, severe, spasmodic; referred to epigastrium, umbilicus

Distention, minimal rebound tenderness, vomiting, localized tenderness, visible peristalsis; bowel sounds absent (with paralytic obstruction) or hyperactive high-pitched (with mechanical obstruction)

Volvulus

Referred to hypogastrium and umbilicus

Distention, nausea, vomiting, guarding; sigmoid loop volvulus may be palpable

Leaking abdominal aneurysm

Steady throbbing midline over aneurysm; may penetrate to back, flank

Nausea, vomiting, abdominal mass, bruit

Biliary stones, colic

Episodic, severe, RUQ, or epigastrium lasting 15 min to several hours; may be referred to subscapular area, especially right

RUQ tenderness, soft abdominal wall, anorexia, vomiting, jaundice, subnormal temperature

Renal calculi

Intense; flank, extending to groin and genitals; may be episodic

Fever, hematuria; + Kehr sign

Ectopic pregnancy

Lower quadrant; referred to shoulder; with rupture is agonizing

Hypogastric tenderness, symptoms of pregnancy, spotting, irregular menses, soft abdominal wall, mass on bimanual pelvic examination; ruptured: shock, rigid abdominal wall, distention; + Kehr, Cullen signs

Ruptured ovarian cyst

Lower quadrant, steady, increases with cough or motion

Vomiting, low-grade fever, anorexia, tenderness on pelvic examination

Splenic rupture

Intense; LUQ, radiating to left shoulder; may worsen with foot of bed elevated

Shock, pallor, lowered temperature

LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.

* See table on p. 168 for explanation of signs.

Differential Diagnosis: Common Conditions Producing Chronic Abdominal Pain

Condition

Usual Pain Characteristics

Possible Associated Findings

Irritable bowel syndrome

Hypogastric pain; crampy, variable, infrequent; associated with bowel function

Unremarkable physical examination; pain associated with gas, bloating, distention; relief with passage of flatus, feces

Lactose intolerance

Crampy pain after drinking milk or eating milk products

Associated diarrhea; unremarkable physical examination

Diverticular disease

Localized pain

Abdominal tenderness, fever

Constipation

Colicky or dull and steady pain that does not progress or worsen

Fecal mass palpable, stool in rectum

Uterine fibroids

Pain related to menses, intercourse

Palpable myoma(s)

Hernia

Localized pain that increases with exertion or lifting

Hernia on physical examination

Esophagitis/GERD

Burning, gnawing pain in midepigastrium, worsens with recumbency

Unremarkable physical examination

Peptic ulcer

Burning or gnawing pain

May have epigastric tenderness on palpation

Gastritis

Constant burning pain in epigastrium

May be accompanied by nausea, vomiting, diarrhea or fever; unremarkable physical examination

   

Dains et al, 2003.

Differential Diagnosis of Urinary Incontinence

Condition

History

Physical Findings

Stress incontinence

Small-volume incontinence with coughing, sneezing, laughing, running; history of prior pelvic surgery

Pelvic floor relaxation; cystocele, rectocele; lax urethral sphincter; loss of urine with provocative testing; atrophic vaginitis; postvoid residual <100 mL

Urge incontinence

Uncontrolled urge to void; large-volume incontinence; history of central nervous system (CNS) disorders such as stroke, multiple sclerosis, parkinsonism

Unexpected findings only as related to CNS disorder; postvoid residual <100 mL

Overflow incontinence

Small-volume incontinence, dribbling, hesitancy; in men symptoms of enlarged prostate—nocturia, dribbling, hesitancy, decreased force and calibre of stream

Distended bladder; prostate hypertrophy; stool in rectum, fecal impaction; postvoid residual >100 mL

In neurogenic bladder—history of bowel problems, spinal cord injury, or multiple sclerosis

Evidence of spinal cord disease or diabetic neuropathy; lax sphincter; gait disturbance

Functional incontinence

Change in mental status, impaired mobility, new environment

Impaired mental status; impaired mobility

Medications—hypnotics, diuretics, anticholinergic agents, α-adrenergic agents, calcium channel blockers

Impaired mental status or unexpected findings only as related to other physical conditions

Pediatric Variations

EXAMINATION

TECHNIQUE

FINDINGS

Inspect abdomen in all four quadrants

Infant’s abdomen should be examined, if possible, during a time of relaxation and quiet. Sucking on a pacifier may help to relax infant.

imageContour/symmetry

EXPECTED:Until the age of 3 years, children’s abdomens will protrude when standing.

imageSurface motion

EXPECTED:Pulsation in epigastric area in infants.

 

UNEXPECTED:Peristaltic waves associated with pyloric stenosis.

Percuss abdomen

imageTone

EXPECTED:More tympany is present in children than adults.

Deeply palpate abdomen

 

imageUmbilical ring

EXPECTED:Children up to 4 years old may have an umbilical hernia.

imageLiver

EXPECTED:Liver may be palpable in young children 2 to 3 cm below costal margin.

 

Age

Liver Span (cm)

6 months

2.4-2.8

12 months

2.8-3.1

24 months

3.5-3.6

3 years

4.0

4 years

4.3-4.4

5 years

4.5-5.1

6 years

4.8-5.1

8 years

5.1-5.6

10 years

5.5-6.1

SAMPLE DOCUMENTATION

Subjective.A 44-year-old woman complains of burning sensation in epigastric area and chest. Occurs after eating, especially with spicy foods. Lasts 1 to 2 hours and is worse when lying down. Sometimes causes bitter taste in mouth. Also feels bloated. Antacids do not relieve symptoms. Denies nausea/vomiting/diarrhea. No cough or shortness of breath.

Objective.Abdomen rounded and symmetric, with white striae adjacent to umbilicus in all quadrants. A well-healed 5-cm white surgical scar evident in right lower quadrant. No areas of visible pulsations or peristalsis. Active bowel sounds audible. Percussion tones tympanic over epigastrium and resonant over remainder of abdomen. Liver span 8 cm at right midclavicular line. On inspiration, liver edge firm, smooth, and nontender. No splenomegaly. Musculature soft and relaxed to light palpation. No masses or areas of tenderness to deep palpation. No costovertebral angle tenderness.