Abdominal Examination OSCE Guide PDF

**Abdominal examination** frequently appears in OSCEs and you'll be expected to pick up the relevant clinical signs using your examination skills. This abdominal examination OSCE guide provides a clear step-by-step approach to examining the gastrointestinal system, with an included video demonstrati...

**Abdominal examination** frequently appears in OSCEs and you'll be expected to pick up the relevant clinical signs using your examination skills. This abdominal examination OSCE guide provides a clear step-by-step approach to examining the gastrointestinal system, with an included video demonstration. Download the abdominal examination [[PDF OSCE checklist]](https://geekymedics.com/wp-content/uploads/2022/05/Abdominal-Examination.pdf), or use our [[interactive OSCE checklist]](https://geekymedics.com/abdominal-examination/#checklist). You may also be interested in our [[paediatric abdominal examination guide]](https://geekymedics.com/paediatric-abdominal-examination-osce-guide/). **Introduction** **Wash your hands** and **don PPE** if appropriate. Introduce yourself to the patient including your **name** and **role**. Confirm the patient's **name** and **date of birth**. Briefly **explain** what the examination will involve using **patient-friendly** **language**. **Gain consent** to proceed with the examination. Adjust the head of the bed to a **45° angle **and ask the patient to lay on the bed. Adequately **expose** the **patient's abdomen** for the examination from the waist up (offer a blanket to allow exposure only when required and if appropriate, inform patients they do not need to remove their bra). Exposure of the patient's **lower legs** is also helpful to assess for peripheral oedema. Ask the patient if they have any **pain** before proceeding with the clinical examination. You might also be interested in our premium collection of [**[1,300+ ready-made OSCE Stations]**](https://app.geekymedics.com/osce-stations/), including a range of **clinical examination** stations  **General inspection** **Clinical signs** Inspect the patient from the **end of the bed** whilst at rest, looking for clinical signs suggestive of underlying pathology: - - - - - - - - - - - **Objects and equipment** Look for **objects** or **equipment** on or around the patient that may provide useful insights into their medical history and current clinical status: - - - - - - - - - Abdominal inspection -  1. [](https://geekymedics.com/abdominal-examination/) 2. [](https://geekymedics.com/abdominal-examination/) 3. [](https://geekymedics.com/abdominal-examination/) - [[\]](https://geekymedics.com/abdominal-examination/) **Hands** The **hands** can provide lots of clinically relevant information and therefore a focused, structured assessment is essential. **Inspection** **Palms** **Inspect the palms** for any of the following signs: - - - **Nail signs** **Inspect the nails** for any of the following signs: - - **Finger clubbing** Finger clubbing involves **uniform soft tissue** **swelling** of the **terminal** **phalanx** of a **digit** with subsequent **loss of the normal angle** between the **nail** and the **nail bed**. Finger clubbing is associated with several underlying disease processes, but those most likely to appear in an abdominal OSCE station include **inflammatory bowel disease,** **coeliac disease, liver cirrhosis **and** lymphoma of the gastrointestinal tract**. To** assess **for** finger clubbing:** - - - **Asterixis (flapping tremor)** **Asterixis** (also known as 'flapping tremor') is a type of negative myoclonus characterised by irregular lapses of posture causing a flapping motion of the hands. In the context of an abdominal examination, the most likely underlying cause is either hepatic encephalopathy (due to hyperammonaemia) or uraemia secondary to renal failure. CO~2~ retention secondary to type 2 respiratory failure is another possible cause of asterixis. - - - **Palpation** **Temperature** Place the **dorsal aspect** of your hand onto the patient's to assess **temperature**: - - **Radial pulse** **Assess** the patient's **radial pulse**: - - **Dupuytren's contracture** **Dupuytren's contracture** involves **thickening** of the **palmar fascia**, resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb. There are a number of factors that have been associated with the development of Dupuytren's contracture including genetics, excessive alcohol use, increasing age, male gender and diabetes. To **assess** for Dupuytren's contracture: - -  - Dupuytren\'s contracture and Palmar erythema -  - Hepatic flap (asterixis) -  - Pallor -  - Leukonychia -  - Dupuytren\'s contracture - [[\]](https://geekymedics.com/abdominal-examination/) -  - A close-up of a hand Description automatically generated -  - A person clapping hands Description automatically generated -  - A close up of a hand Description automatically generated -  - A close up of a fingernail Description automatically generated -  - A close up of a hand Description automatically generated - Dupuytren contracture an abnormal thickening of the skin in the palm of the hand. The skin may develop into a hard lump. Over time, it can cause one or more fingers to curl (contract) or pull in toward the palm. You may not be able to use your hand for certain things. In many cases, both hands are affected. **Arms and axillae** **Arms** **Inspect** the patient's **arms** for the following: - - - **Axillae** Whilst supporting the patient's arm, **inspect** each **axilla** for the following: - - -  - Acanthosis nigricans **Face** **Eyes** Ask the patient to gently **pull down their lower eyelid** and inspect for signs suggestive of gastrointestinal pathology: - - - - - - -  - Conjunctival pallor (anaemia) -  - Conjunctival pallor -  - Corneal arcus -  - Kayser-Fleischer ring -  - [[\]](https://geekymedics.com/abdominal-examination/) - A person with his hand on his forehead Description automatically generated -  - A person with a beard Description automatically generated -  - A close up of a person\'s face Description automatically generated -  - A close up of a person\'s eyes Description automatically generated -  - A close up of an eye Description automatically generated - [[Previous]](https://geekymedics.com/abdominal-examination/) - [[Next]](https://geekymedics.com/abdominal-examination/) **Mouth** Ask the patient to **open their mouth** and inspect for signs suggestive of gastrointestinal pathology: - - - - - -  - angular stomatitis -  - Oral candidiasis -  - Peutz-Jeghers syndrome - [[\]](https://geekymedics.com/abdominal-examination/) -  - A close up of a person\'s mouth Description automatically generated -  - A close up of a white and red spot Description automatically generated -  - Close up of a person\'s mouth Description automatically generated - [[Previous]](https://geekymedics.com/abdominal-examination/) - [[Next]](https://geekymedics.com/abdominal-examination/) **Neck** The **left supraclavicular lymph node** (known as Virchow's node) receives lymphatic drainage from the abdominal cavity and therefore enlargement of Virchow's node can be one of the first clinical signs of **metastatic intrabdominal malignancy** (most commonly gastric cancer). The right supraclavicular lymph node receives lymphatic drainage from the thorax and therefore lymphadenopathy in this region can be associated with metastatic oesophageal cancer (as well as malignancy from other thoracic viscera). **Palpate for lymphadenopathy** **Palpate** the **supraclavicular fossa** on each side, paying particular attention to Virchow's node on the left for evidence of lymphadenopathy. -  - [[\]](https://geekymedics.com/abdominal-examination/) **Chest** Inspect the patient's **chest** for signs suggestive of gastrointestinal pathology: - - - - Spider naevia -  1. [](https://geekymedics.com/abdominal-examination/) 2. [](https://geekymedics.com/abdominal-examination/) - [[\]](https://geekymedics.com/abdominal-examination/) **Abdominal inspection** Position the patient** lying flat** on the bed, with their **arms by their sides** and **legs uncrossed** for abdominal inspection and subsequent palpation. Inspect the patient's **abdomen** for signs suggestive of gastrointestinal pathology: - - - - - - - - Abdominal regions -  - Ascites and caput medusae -  - Umbilical hernia -  - Cullen\'s sign -  - [[\]](https://geekymedics.com/abdominal-examination/) - A person\'s back with a drawing on it Description automatically generated -  - A close up of a pregnant belly Description automatically generated -  - A close up of a person\'s stomach Description automatically generated -  - A close up of a dog\'s skin Description automatically generated -  - [[Previous]](https://geekymedics.com/abdominal-examination/) - [[Next]](https://geekymedics.com/abdominal-examination/) **Stomas** If a **stoma** is present, assess the following characteristics: - - - - - Colostomy -  1. [](https://geekymedics.com/abdominal-examination/) 2. [](https://geekymedics.com/abdominal-examination/) - [[\]](https://geekymedics.com/abdominal-examination/) **Abdominal palpation** **Preparation** **Before** beginning **abdominal** **palpation**: - - - **Light palpation of the abdomen** **Lightly palpate** each of the **nine abdominal regions**, assessing for clinical signs suggestive of gastrointestinal pathology: - - - - - - **Deep palpation of the abdomen** Palpate each of the nine abdominal regions again, this time applying **greater pressure** to identify any **deeper masses**. Warn the patient this may feel uncomfortable and ask them to let you know if they want you to stop. You should also carefully monitor the patient's face for evidence of discomfort (as they may not vocalise this). If any **masses** are identified during deep palpation, assess the following characteristics: - - - - - - Abdominal palpation -  1. [](https://geekymedics.com/abdominal-examination/) 2. [](https://geekymedics.com/abdominal-examination/) - [[\]](https://geekymedics.com/abdominal-examination/) **Palpate the liver** **1. **Begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (the radial side of your right index finger). **2. **Ask the patient to take a deep breath and as they begin to do this palpate the abdomen. Feel for a step as the liver edge passes below your hand during inspiration (a palpable liver edge this low in the abdomen suggests gross hepatomegaly). **3.** Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the right costal margin. **4.** As you get close to the costal margin (typically 1-2 cm below it) the liver edge may become palpable in healthy individuals. If you are able to identify the **liver edge**, assess the following characteristics: - - - - **Causes of hepatomegaly** There is a wide range of possible causes of **hepatomegaly** including but not limited to: - - - - - - - - - - - - Liver palpation (hepatomegaly) -  1. [](https://geekymedics.com/abdominal-examination/) 2. [](https://geekymedics.com/abdominal-examination/) - [[\]](https://geekymedics.com/abdominal-examination/) **Palpate the gallbladder** In healthy individuals, the gallbladder is **not usually palpable**. If the gallbladder is palpable it suggests enlargement secondary to **biliary flow obstruction** (e.g. pancreatic malignancy, gallstones) and/or infection (e.g. cholecystitis).  Palpation of the gallbladder can be attempted at the **right costal margin**, in the **mid-clavicular line** (the tip of the 9th rib). If the gallbladder is enlarged, a **well-defined round mass** that **moves with respiration** may be noted. Tenderness suggests a diagnosis of cholecystitis whereas a distended painless gallbladder may indicate underlying pancreatic cancer (particularly if also associated with jaundice). **Murphy's sign** **1. **Position your fingers at the right costal margin in the mid-clavicular line at the liver's edge. **2. **Ask the patient to take a deep breath. If the patient suddenly stops mid-breath due to pain, this suggests the presence of cholecystitis (known as "Murphy's sign positive"). **Palpate the spleen** **1. **Begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (the radial side of your right index finger). **2. **Ask the patient to take a deep breath and as they begin to do this palpate the abdomen with your fingers aligned with the left costal margin. Feel for a step as the splenic edge passes below your hand during inspiration (the splenic notch may be noted). **3.** Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the left costal margin. In healthy individuals, you should **not** be able to palpate the spleen. A palpable spleen at the edge of the left costal margin would suggest **splenomegaly** (for the spleen to be palpable at this location it would need to be approximately three times its normal size). **Causes of splenomegaly** There is a wide range of possible causes of splenomegaly including but not limited to: - - - - - - Spleen palpation (splenomegaly) -  1. [](https://geekymedics.com/abdominal-examination/) 2. [](https://geekymedics.com/abdominal-examination/) - [[\]](https://geekymedics.com/abdominal-examination/) **Ballot the kidneys** **1.** Place your left hand behind the patient's back, below the ribs and underneath the right flank. **2.** Then place your right hand on the anterior abdominal wall just below the right costal margin in the right flank. **3. **Push your fingers together, pressing upwards with your left hand and downwards with your right hand. **4.** Ask the patient to take a deep breath and as they do this feel for the lower pole of the kidney moving down between your fingers. This bimanual method of kidney palpation is known as balloting. **5.** If a kidney is ballotable, describe its size and consistency. **6.** Repeat this process on the opposite side to ballot the left kidney. In healthy individuals, the kidneys are not usually ballotable, however, in patients with a low body mass index, the inferior pole can sometimes be palpated during inspiration. **Causes of enlarged kidneys** - - - Ballot the kidneys - [[\]](https://geekymedics.com/abdominal-examination/) **Palpate the aorta** **1. **Using both hands perform deep palpation just superior to the umbilicus in the midline. **2. **Note the movement of your fingers: - - This is a crude clinical test and further investigations would be required before a diagnosis of an abdominal aortic aneurysm was made. -  - [[\]](https://geekymedics.com/abdominal-examination/) **Palpate the bladder** Before performing **bladder** **palpation**, allow the patient the opportunity to go to the toilet. **Warn the patient** that palpation may be uncomfortable and bring about the sudden urge to pass urine. A distended bladder can be palpated in the** suprapubic area** arising from behind the **pubic symphysis** (e.g. urinary obstruction/retention). In most healthy patients who are passing urine regularly, the bladder will **not** be palpable. **Abdominal percussion** **Percuss the liver** **1. **Percuss upwards 1-2 cm at a time from the right iliac fossa (the same position used to begin palpation) towards the right costal margin until the percussion note changes from resonant to dull indicating the location of the lower liver border. **2.** Continue to percuss upwards 1-2 cm at a time until the percussion note changes from dull to resonant indicating the location of the upper liver border. **3. **Use the knowledge of the upper and lower border of the liver to determine its approximate size. - Liver percussion (hepatomegaly) - [[\]](https://geekymedics.com/abdominal-examination/) **Percuss the spleen** Percuss upwards 1-2 cm at a time from the right iliac fossa (the same position used to begin palpation) towards the left costal margin until the percussion note changes from resonant to dull indicating the location of the spleen (in the absence of splenomegaly the spleen should not be identifiable using percussion). -  **Percuss the bladder** Percuss downwards in the midline from the umbilical region towards the pubic symphysis. A distended bladder will be dull to percussion allowing you to approximate the bladder's upper border. - Percuss bladder (urinary retention) - [[\]](https://geekymedics.com/abdominal-examination/) **Assess shifting dullness** **Percussion** can also be used to assess for the presence of **ascites** by identifying** shifting dullness**: **1. **Percuss from the umbilical region to the patient's left flank. If dullness is noted, this may suggest the presence of ascitic fluid in the flank. **2.** Whilst keeping your fingers over the area at which the percussion note became dull, ask the patient to roll onto their right side (towards you for stability). **3. **Keep the patient on their right side for 30 seconds and then repeat percussion over the same area. **4. **If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness has shifted). -  - Shifting dullness **Abdominal auscultation** **Assess bowel sounds** **Auscultate** over **at least two** **positions** on the abdomen to** assess bowel sounds**: - - - **Listen for bruits** **Auscultate** over the **aorta** and **renal arteries** to identify **vascular** **bruits** suggestive of turbulent blood flow: - - -  - Aortic bruit -  1. [](https://geekymedics.com/abdominal-examination/) 2. [](https://geekymedics.com/abdominal-examination/) 3. [](https://geekymedics.com/abdominal-examination/) - [[\]](https://geekymedics.com/abdominal-examination/) **Legs** Assess the patient's **lower legs** for evidence of **pitting oedema** which may suggest **hypoalbuminaemia** (e.g. liver cirrhosis, protein-losing enteropathy). - Pitting pedal oedema - [[\]](https://geekymedics.com/abdominal-examination/) **To complete the examination...** **Explain** to the patient that the examination is now **finished**. **Thank the patient** for their time. **Dispose of PPE** appropriately and **wash your hands**. **Summarise** your findings. **Example summary** *"Today I examined **Mrs Smith**, a **64-year-old female**. On **general inspection**, the patient appeared comfortable at rest, with no evidence of abdominal distension or jaundice. There were no objects or medical equipment around the bed of relevance."* *"The **hands** had no peripheral stigmata of gastrointestinal disease and were symmetrically warm. There was no evidence of asterixis."* *"The **pulse** was regular at 70 beats per minute."* *"The **arms** did not have any evidence of bruising or excoriations and the **axillae** were unremarkable."* *"On **inspection of the face**, there were no stigmata of gastrointestinal disease."* *"There was no evidence of **lymphadenopathy** in the supraclavicular region."* *"**Closer inspection of the chest** did not reveal any stigmata of gastrointestinal disease."* *"On **inspection of the abdomen**, no scars, distension or hernias were noted. **Abdominal palpation** and **percussion** were unremarkable with no evidence of organomegaly. **Bowels sounds** were normal and no bruits were noted."* *"There was no evidence of peripheral **oedema** on the assessment of the legs."* *"In **summary**, these findings are consistent with a **normal** **abdominal** **examination**."* *"For completeness, I would like to perform the following **further assessments** and **investigations**."* **Further assessments and investigations** - - - Select the sequence of techniques used during an examination of the abdomen\ a. Purcussion, inspection, palpation, auscultation\ b. Inspection, palpation, purcussion, ausculatation\ c. Inspection, auscultation, percussion, palpation\ d. Auscultation, inspection, palpation, percussion c\. Inspection, auscultation, percussion, palpation Which of the following may be noted through inspection of the abdomen\ a. Fluid waves and abdominal contour\ b. Umbilical eversion and Murphy\'s sign\ c. Venous pattern, peristaltic waves, and abdominal contour\ d. Peritoneal irritation, general tympany, and peristaltic waves c\. Venous pattern, peristaltic waves, and abdominal contour Right upper quadrant tenderness may indicate pathology in the:\ a. Liver, pancreas, or gallbladder\ b. Liver and stomach\ c. Sigmoid colon, spleen, or rectum\ d. Appendix or ileocecal valve Hyperactive bowel sounds are:\ a. High pitched\ b. Rushing\ c. Tinkling\ d. All of the above The absence of bowel sounds is established after listening for:\ a. 1 full minute\ b. 3 full minutes\ c. 5 full minutes\ d. None of the above Auscultation of the abdomen may reveal bruits of which arteries?\ a. Aortic, renal, iliac, and femoral\ b. Jugular, aortic, carotid, and femoral\ c. Pulmonic, aortic, and portal\ d. Renal, iliac, internal jugular, and basilic The range of normal liver span in the right midclavicular line in the adult is:\ a. 2-6 cm\ b. 4-8 cm\ c. 8-14 cm\ d. 6-12 cm The left upper quadrant (LUQ) contains the:\ a. Liver\ b. Appendix\ c. Left ovary\ d. Spleen Striae, which occur when the elastic fibres in the reticular layer of the skin are broken following rapid or prolonged stretching, have a distinct colour when of long duration. This colour is:\ a. Pink\ b. Blue\ c. Purple-blue\ d. Silvery white Auscultation of the abdomen is begun in the right lower quadrant (RLQ) because:\ a. Bowel sounds are always normally present here\ b. Peristalsis through the defending colon is usually active\ c. This is the location of the pyloric sphincter\ d. Vascular sounds are best heard in this area [**We have an expert-written solution to this problem!**](https://quizlet.com/explanations/questions/auscultating-the-abdomen-is-begun-in-the-right-lower-quadrant-rlq-because-a-bowel-sounds-are-always-normally-present-here-b-peristalsis-thro-6c7e3873-98bdca6f-df62-4eee-afaf-1eda976bedc5) A dull percussion note forward of the left midaxillary line is:\ a. Normal, an expected finding during splenic percussion\ b. Expected between the eighth and twelfth ribs\ c. Found if the examination follows a large meal\ d. Indicative of splenic enlargement d\. Indicative of splenic enlargement Shifting dullness is a test for:\ a. Ascites\ b. Splenic enlargement\ c. Inflammation of the kidney\ d. Hepatomegaly Tenderness during abdominal palpation is expected when palpating\ a. The liver edge\ b. The spleen\ c. The sigmoid colon\ d. The kidneys Murphy\'s sign is best described as:\ a. The pain felt when the hand of the examiner is rapidly removed from the inflamed appendix\ b. Pain felt when taking a deep breath when the examiner\'s fingers are on the approximate location of the inflamed gallbladder\ c. A sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle\ d. Not a valid examination technique What does a physical exam of the abdomen consist of? 1\) Inspection 2\) Auscultation 3\) Percussion 4\) Palpation This structure is soft an difficult to feel through the abdominal wall The liver This structure rests on the inferior surface of the liver and more deeply lying duodenum The gallbladder This structure may be felt in a thin person with abdominal muscles relaxed The right kidney This structure often times has a visible pulsation in the upper abdomen The abdominal aorta What structures are in the RUQ? 1\) Liver 2\) Gall Bladder 3\) Pylorus 4\) Duodenum 5\) Head of Pancreas 6\) Right adrenal gland 7\) Superior Aspect of Right Kidney 8\) Hepatic Flexure of ascending colon 9\) Portions of ascending and transverse colon Where is the Spleen? \- The \"spleen\" is lateral to and behind the \"stomach\" just above the \"left kidney\" in the L MAL What ribs protect most of the spleen? Ribs 9-10-11. The tip of the spleen may be palpable below the left costal margin in a small percentage of adults Is the pancreas palpable in healthy adults? No What are the organs of LUQ? 1\) Left lobe of the liver 2\) Spleen 3\) Stomach, body of pancreas 4\) Left arena gland and upper aspect of left kidney 5\) Splenic flexure of colon 6\) Portion of transverse and descending colon What is palpable in the LLQ? \- Can often feel the firm narrow tubular sigmoid colon \- Portions of the transverse and descending colon \- In the lower mid line are the bladder, the sacral promontory the bony anterior edge of the S1 vertebra, and in women the uterus and ovaries What are the organs of the LLQ 1\) Lower lobe of left kidney 2\) Sigmoid colon 3\) portion of descending colon 4\) Left Ureter (bladder if distended) 5\) Left overt and tube (uterus if enlarged) Where are the bowel loops and the appendix at the tail of the cecum near the junction of the small and large intestines? RLQ What are the organs of the RLQ? 1\) Lower pole of right kidney 2\) Cecum and appendix 3\) Portion of ascending colon 4\) Right ovary and tube (uterus if enlarged) 5\) Right ureter (bladder if distended) Where might a distended bladder be palpable? Above the symphysis pubis How much urine is accommodated before smooth muscle and detrusor muscle are stimulated to contract? about 300 ml Are the kidneys easy to palpate? no What is the angle formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae The Costovertebral angle (CVA) What is the area to test for kidney tenderness? The CVA What does flexing the knees during examination do? Helps relax tension on the abdominal muscles Positioning the patient supine with arms at sides exposes the entire abdomen from\_\_\_\_\_\_\_\_ to the \_\_\_\_\_\_\_\_\_\_\_\_\_ xyphoid to suprapubic area What side should you stand at? the patients right side What can the patient do to assist in evaluation? Point to any areas of tenderness What are the orders of evaluation of the abdomen? 1\) Inspection 2\) Auscultation 3\) Percussion 4\) Palpation What is an inflammation (irritation) of the peritoneum (the tissue that lines the wall of the abdomen and covers the abdominal organs? Peritonitis What do patients with peritonitis usually do? Lie still as movement lead to pain On the other hand, what type of patient \"Constantly Moves\" in order to gain comfort? Patients with obstructions of the colon, small intestine, and stones of the kidney and gall bladder Flat Contour abdomen indicates Healthy Round Contour abdomen indicates Obese Protuberant or distended abdomen indicates Prominent convexity of the abdomen due to excessive subcutaneous or visceral fat, poor muscle tone, or an increase in the contents of the abdomen Scaphoid (hollowed) abdomen indicates malnutrition Flanks that bulge indicate Ascities Local bulges in the abdomen indicate Hernia Visible Masses in the abdomen indicate Lipomas, Hernias Asymmetry of the abdomen can indicate Organomegaly, tumor Increased peristaltic waves indicate Intestinal obstruction A normal aortic pulsation may be visible in the epigastrium, but may be widened with an Aneurysm Enlarged veins may due to: 1\) Emaciation 2\) Portal hypertension 3\) Inferior Vena Cava Obstruction What is emaciation? Loss of SC fat- normal (invisible) veins become prominent What is portal hypertension? Umbilical vein becomes an outflow tract of the portal system and forms collaterals with veins of the abdominal wall (CAPUT MEDUSA)\--\> Diagnostic of portal hypertension What are Cullen\'s and Grey Turner\'s signs Bluish discoloration of the umbilicus and the flanks What are Cullen\'s and Grey Turner\'s signs indicative of? Intra-abdominal and retroperitoneal bleeding How does blood get to the bruising sites? Blood dissects along fascial planes to reach these areas What is striae? A result of rupture of reticular dermis that occurs with stretching Where is striae seen clinically? 1\) Pregnancy 2\) Obesity 3\) Ascities 4\) Cushing\'s syndrom Wounds that heal by first intention are: Thin and regular Wounds that are infected and heal by secondary intention are: Wider and irregular Kocher\'s Incision Choleocystectomy Right Paramedian Laparotomy Midline Laparotomy Gridiron Incision Appendectomy Laparoscopic 1\) Choleocystectomy 2\) Appendectomy 3\) Coectomies Left Paramedian Ant rectal resection Transverse Suprapubic 1\) Hysterectomy 2\) Other pelvic surgery Inguinal hernia Hernia repair Mass in the Epigastric area may be: Acute gastric distention, pancreatic pseudocyst/cancer, or aneurysm of abdominal aorta (AAA), which will be pulsatile Mass in the LUQ may be: Splenomegaly or carcinoma of the splenic flexure of the colon Mass in the LLQ may be: Diverticular abscess or carcinoma of the sigmoid colon Mass in the Hypogastric area may be: Pelvic pathology such as acute urinary retention in males, or uterine/ovarian neoplasms in females Mass in the RLQ may be: Appendiceal abcess or cecal carcinoma Mass in the RUQ may be: Hepatomegaly from hepatitis or hepatic tumor, distended gallbladder from choleystitis or pancreatic cancer This is a protrusion through a defective umbilical ring Umbilical ring What population does an umbilical hernia usually affect and how does it resolve Usually in infants and usually closes spontaneously within 1-2 years What is a common protrusion through an operative scar? An incisional hernia; Palpate and detect the length and width in the abdominal wall What is a small midline protrusion through a \"defect in the linea alba\" between the xiphoid and the umbilicus? An Epigastric Hernia This protrudes when patient raises head or shoulders What is the separation of the two rectus abdomens muscles, through which abdominal contents form a \"midline ridge\" when the patient raises their head and shoulders? Diastasis Recti What populations do you normally see Diastasis Recti? 1\) Repeated pregnancies 2\) Obesity 3\) Chronic Lung disease Is Diastasis Recti of clinical significance? No What is a benign, fatty tumor usually located in the subcutaneous tissues almost anywhere on the body? Lipoma. They are soft, often lobulated and mobile When do we Auscultate the abdomen and why? Performed before percussion and palpation; both of which can change bowel sounds How many areas do we need to listen to in order to ascertain bowel sounds? One; with the Diaphragm What information does bowel auscultation provide? Bowel motility What are Normal Active Bowel Sounds (NABS) Active (5-35/minute) What would cause increased or hyperactive bowel sounds? Diarrhea, hunger or early intestinal obstruction What does high pitched tinkling suggest? Intestinal fluid and air under tension in a dilated bowel What does rushes of high-pitched sounds coinciding with an abdominal cramp indicate? Intestinal obstruction Absent, or decreased or hypoactive bowel sounds indicate\_\_\_\_\_\_\_ Ileus or peritonitis How long should we listen before declaring bowel sounds are absent? 2 minutes What is the sound that your stomach makes when you are hungary? Borborygmi What would the absence of bowel sounds indicate? Intra-abdominal infection in the patient with multiple problems and particularly, altered mental status In a patient with generalized distention, following laparotomy, Bowel Signs may be the key diagnostic finding in differentiating \_\_\_\_\_\_\_ from \_\_\_\_\_\_\_ Ileus from early postop small bowel obstruction (SBO) Though a radiographic exam may \"SUGGEST\" bowel obstruction, how do we diagnose small bowel obstruction? The high pitched bowels using a STETHOSCOPE GUYS!!! YOU KNOW THIS What is the most common cause of an ileus? Post operative states. As a matter of fact, it is expected!! What is a vascular sound due to turbulent blood flow that resemble systolic murmurs Bruits While listening for bruits, what should we be cautious of with a HTN patient? Renal artery stenosis When auscultating you hear bruits in the abdomen of a patient with chronic abdominal pain, what should you be concerned with? Mesenteric arterial insufficiency With a patient that has claudication, what is the concern? Occlusive disease of the aorta or iliac arteries Where is the abdominal aorta? In the midline between typhoid and umbilicus Where is the renal artery? approx. 1 inch lateral of midline in the upper quadrants Where is the iliac artery? Just inside the midpoint on the line drawn from the umbilicus to the anterior superior iliac spine (ASIS) Where is the femoral artery? Midpoint in the groin crease The patient should be in supine with what assessment procedures? Inspection and Auscultation Why do we percuss the abdomen? It helps to assess the amount and distribution of gas in the abdomen and identify any solid or fluid filled masses What sounds are we listening for when percuss the abdomen? Assess for distribution tympanny and dullness Why does tympany normally predominate? Because of the gas in the GI tract, though scattered areas of dullness from fluid and feces are also found What would a large area of dullness indicate? Mass or enlarged organs What does a protuberant abdomen that is tympanitic throughout suggest? Intestinal obstruction What sound does the liver make? Dull What sound does the splenic flexure and colon make tympany What can help differentiate between localized tenderness from generalized tenderness (as with peritonitis) Percussion supine with hands resting on center of chest or arms resting at the sides and legs bent at the knees, goal is to promote comfort and relaxation of the abdominal muscles which enhances all aspects of the exam, especially palpation; place drape or sheet at the level of the symphysis pubis and raise gown to just below the nipple line above the xiphoid process (entire abdomen should be visible) patient positioning for an abdominal examination position yourself at patient\'s right side and proceed in a systemic fashion with inspection, auscultation, percussion, and palpation; watch patient\'s face for any signs of pain or discomfort and examine painful areas last steps of abdominal exam in order important to follow the direction of peristalsis - theoretically could create an ileus if performed against the direction of peristalsis (although would likely require significant manipulation) reason it is important to examine the abdomen in a clockwise fashion starting at RLQ skin, umbilicus, contours, symmetry, herniation and diastasis recti (bulge of the abdomen when head is raised off the table/bed), abdominal movement, temperature components of abdominal inspection color, vascularity, striae, scars, dilated veins, lesions (ex. rashes or ecchymosis) abnormalities to note on abdominal skin inspection paler than general skin tone - can be normal due to less exposure, may also be seen with ascites along with a taut abdomen; purple - possible trauma, purple striae indicates Cushing\'s disease; yellow - jaundice; redness - inflammation meaning of various color changes when examining skin of the abdomen intraperitoneal or retroperitoneal hemorrhage ecchymosis of the abdominal wall may be a sign of color, location, contour; note any bulges or inflammation, enlarged everted appearance may indicate umbilical hernia abnormalities to note on inspection of umbilicus flat, scaphoid (concave/hollowed), rounded, distended/protuberant, obese descriptors of the contour of the abdomen organ enlargement, large masses, hernia, diastasis recti, bowel obstructions possible causes of abdominal asymmetry abdominal respiratory movements, aortic pulsations, peristaltic waves abdominal movements that may be visible on physical exam palpation may alter the characteristics of bowel sounds reason it is important that palpation is the last part of the abdominal physical exam start in the RLQ and proceed clockwise; auscultate for bowel sounds in all 4 quadrants and note the intensity, pitch, character, and frequency; listen over liver and spleen for friction rubs; auscultate for vascular sounds (ex. bruits, venous hum) using the bell of the stethoscope steps of abdominal auscultation soft clicks and gurgles at a rate of 5 to 34 per minute, borborygmus (growling or rumbling) characteristics of normoactive bowel sounds hyperactive \>34/minute, hypoactive \