Perfecting The Gastrointestinal Physical Exam PDF

Perfecting the G a s t ro i n t e s t i n a l P h y s i c a l Exam Findings and Their Utility and Examination Pearls Liza DiLeo Thomas, MD, CPXP, FAAEM, FACEPa,*, Megan C. Henn, MD, FACEPb KEYWORDS  Physical examination  Abdominal  Emergency  Peritoneal signs  Rebound  Analgesia KEY POI...

Perfecting the G a s t ro i n t e s t i n a l P h y s i c a l Exam Findings and Their Utility and Examination Pearls Liza DiLeo Thomas, MD, CPXP, FAAEM, FACEPa,*, Megan C. Henn, MD, FACEPb KEYWORDS  Physical examination  Abdominal  Emergency  Peritoneal signs  Rebound  Analgesia KEY POINTS  The abdominal examination is an essential part of the physical examination of the emer- gency medicine patient.  The basic abdominal physical examination can be broken down into different compo- nents: inspection/exposure, percussion, auscultation, and palpation.  Knowing how to perform an excellent abdominal examination can help narrow your differ- ential diagnosis and serve to minimize further testing in the emergency department.  Sensitivity and specificity for clinical signs varies; a working knowledge of their limitations is necessary to use these signs in daily practice.  Special populations including children, the elderly, pregnant, and unstable patients pose diagnostic challenges making the abdominal examination more difficult but still useful. INTRODUCTION TO THE ABDOMINAL EXAMINATION A complete examination of the abdomen is typically composed of several elements — inspection, percussion, auscultation, and palpation of the abdomen, as well as exam- ination of the head, neck, mouth, and rectum, when indicated. Patient positioning and comfort are critical in achieving a reliable examination.1 The examination of the abdomen should also include an overall evaluation of the patient. While elderly a Department of Emergency Medicine, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA; b Department of Emergency Medicine, Emory University, 531 Asbury Circle, Annex Building, Suite N340, Atlanta, GA 30322, USA * Corresponding author. E-mail address: [email protected] Twitter: @lzzza3 (L.D.T.); @megan_henn (M.C.H.) Emerg Med Clin N Am 39 (2021) 689–702 https://doi.org/10.1016/j.emc.2021.07.004 emed.theclinics.com 0733-8627/21/ª 2021 Elsevier Inc. All rights reserved. Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved. 690 DiLeo Thomas & Henn patients can appear well even with life-threatening pathology, an ill-appearing patient with abdominal pain should be urgently evaluated as there are many concerning po- tential etiologies of their pain.2 While this part of the examination is only one piece of a thorough history and physical examination, it can reveal much about the patient’s gen- eral health as well as the acute complaint. ELEMENTS OF THE ABDOMINAL EXAMINATION Inspection/Exposure Before examining a patient, the examiner should obtain consent. After thoroughly washing hands, the examiner should explain to the patient the reason for the exami- nation and the steps that will be involved. Inspection of the abdomen is the beginning of a thorough abdominal examination and should not be omitted as it can reveal a great deal about the patient. The abdomen should be fully exposed from the chest wall to the pubic symphysis, and the patient positioned in a comfortable, supine po- sition allowing for abdominal muscle relaxation,1 ideally with the knees and head sup- ported.3 The patient’s hands should be at the side or folded across the chest. The visual examination of the shape, skin, color, and movement of the abdomen begins the search for pathology.3 The examiner should inspect the skin for color, rash, wounds, scars, and medical equipment, customarily observed from the patient’s right side or from the foot of the bed.3,4 Skin inspection can reveal a great deal about the patient’s general health as well as findings that may indicate abdominal pathology. For example, surgical scars or more recent healing incisions, a vesicular rash consistent with zoster, striae indi- cating possible Cushing’s syndrome,1 bluish discoloration at the umbilicus (Cullen’s sign) or the flanks (Grey Turner’s sign),1 dilated abdominal wall veins (Fig. 1), or an os- tomy or stoma may be present. Fig. 1. Stigmata of liver disease. Dilated abdominal wall veins associated with cirrhosis and portal hypertension. (Jackson JM, Callen JP, Greer KE. Dermatological Signs of Systemic Dis- ease. 2017. Page 255-261.) Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.  Perfecting the Abdominal Exam 691 The examiner should observe the contour and shape of the abdomen. The presence of ascites, a gravid uterus, enlarged abdominal girth, or distention may be appreci- ated. Visible masses that could indicate hernias (Fig. 2), tumors, lymphadenopathy, or infection should also be denoted. Asking the patient to contract the abdominal mus- cles may provide additional visual clues as muscle tension will make a mass within the abdominal wall more apparent while relaxation of the abdominal wall will make a mass within the abdominal cavity more prominent.1 Movement observed in the abdominal wall can include the use of accessory mus- cles for increased work of breathing, pulsatile masses in the case of an abdominal aortic aneurysm (AAA), or peristalsis indicating a possible bowel obstruction. Auscultation The abdominal examination continues with auscultation of bowel sounds. Classic medical textbooks suggest that this portion of the examination usually precedes per- cussion and palpation because of the possibility of disturbing the bowel sounds during those portions of the examination. However, a randomized controlled trial by Calis and colleagues5 found that the order of the examination did not change the frequency of bowel sounds. Bowel sounds can be heard best with the use of the stethoscope dia- phragm, usually in one location such as the right lower quadrant, as bowel sounds are transmitted throughout the abdomen.6 The examiner may occasionally hear borbo- rygmi, what we typically describe as the “stomach growling,” which corresponds with loud, prolonged sounds of hyperperistalsis.6 A normal frequency of bowel sounds is every 5 to 10 seconds,1 and an increase or decrease in frequency of bowel sounds can indicate pathology of the bowels. Bowel sounds may be increased in diarrheal ill- nesses or early intestinal obstruction. They may be decreased and eventually absent in processes such as ileus and peritonitis.6 High-pitched tinkling sounds may indicate intestinal obstruction because those sounds may correspond with air under tension in a dilated bowel.6 However, auscultation of bowel sounds is not altogether reliable and is time-intensive2 as the examiner must listen for a full 3 minutes to establish that bowel sounds are truly absent.3 Also, diminished or absent bowel sounds may not be present in intestinal obstruction and is an unreliable indicator of a perforated viscus or other surgical abdomen.7 Fig. 2. Inguinal hernia. Left indirect inguinal hernia. (Merritt R, Clyne B. Ferri’s Clinical Advisor 2021. Page 799.) Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved. 692 DiLeo Thomas & Henn In addition to bowel sounds, the examiner may hear vascular bruits of the renal, iliac, or femoral arteries.1 If these bruits are heard only in systole, this may be normal and may not indicate occlusive disease. However, if there are both systolic and diastolic components to the bruits, this suggests turbulent blood flow, and therefore, partial arterial occlusion is likely present.6 Percussion Percussion of the abdomen can be used to determine the nature of an abdominal mass and help maximize knowledge of intra-abdominal pathology. In order to appro- priately perform percussion, the examiner should place the second or middle finger of the nondominant hand firmly on the area to be percussed and hyperextend it.6,8 Con- tacting the area with other parts of the hand, other than this finger, will dampen the vibrations and affect the sound. Then, using the second or middle finger on the domi- nant hand, tap against the middle finger of the resting hand until a sound is heard. The wrist should be moved in a quick striking movement as though it is bouncing off of the other hand,6 similar to a piano hammer.8 The strike should occur just below the nail and with the tip of the finger of the nondominant hand. Tympanitic resonance or tym- pany is obtained over a hollow body and is usually higher in pitch.8 Tympany indicates that a mass is gas filled while dullness implies a mass is solid or fluid filled. During abdominal percussion, if tympany is heard over the umbilicus and there is dullness at the flanks, free fluid in the abdomen may be suspected. While the patient lies su- pine, fluid gravitates to the flanks; therefore, there will be dullness when percussing the flanks and resonance when percussing the epigastric and umbilical regions.8 The examiner can then check for shifting dullness by having the patient lie on one side, waiting 10 seconds or more, and then percussing from the uppermost flank to- ward the umbilicus. A change from tympany to dullness indicates that gas has moved to the top and fluid has shifted down to gravity.4 Without testing for shifting dullness, merely percussing for fluid at the flanks does not conclusively indicate that there is free fluid in the abdomen.8 Percussion can also be used to determine spleen size and liver size while listening for dullness change to tympany as the examiner’s fingers transition from solid organs to gas-filled bowel. As with each part of the abdominal examination, there are limitations to the value of percussion. The examiner may have more difficulty ascertaining difference in sound in patients with an elevated body mass index or those who have edema to the abdominal wall.8 Also, in critically ill patients or those in severe pain, the examiner may need to defer this part of the examination. Palpation Palpation of the abdomen with the intent to identify and localize pain is one of the most useful elements of the abdominal examination. Palpation of the abdomen should be completed with the patient supine and as comfortable as possible. As mentioned pre- viously, the head and knees should be supported to allow the abdominal wall muscles to relax. The examiner should palpate the abdomen twice — initially superficially, fol- lowed by deep palpation to examine each quadrant of the abdomen (Fig. 3). To begin this portion of the examination, the examiner should describe this portion of the examination and its purpose to the patient. To perform the examination, typically the examiner stands to the right side of the patient.4 The examiner’s hands are ideally warm and fingernails are short. If necessary, the examiner may make contact with the patient through the gown if the examiner’s hands are cold.6 The patient can indicate the area of most intense pain and, if there is a focal area, that area should be palpated last, after palpating the rest of the abdomen.8 Palpation should be performed by Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.  Perfecting the Abdominal Exam 693 Fig. 3. Quadrants of the abdomen. (From Joanna Kotcher Fullerb. Surgical Technology – Principles and Practice, 8th edition. Chapter 22 – General Surgery, Fig. 22.2 (caption: The quadrants of the abdomen).) keeping the fingers together and flat against the abdominal surface while the hand and forearm are on the same plane as the supine patient and gliding the hand across the abdomen smoothly while gently dipping into all quadrants. While moving across the abdomen, the examiner should monitor the patient’s facial expressions while both palpating and lifting the hand off the skin just slightly.6 This superficial palpation will reassure and relax the patient while allowing for discovery of areas of tenderness and irregularities that can be further explored on deep palpation. One objective of palpating the abdomen is to localize and quantify tenderness. Describing the pain in reference to its location, depth, and severity can reveal much about the patient’s intra-abdominal pathology. The patient may avoid pain by con- tracting the abdominal wall musculature. This contraction is referred to as guarding. Guarding can be voluntary, where the abdominal wall muscle is contracted to avoid palpation of the intra-abdominal contents,3 or involuntary. Involuntary guarding is a spasm of the abdominal wall that is not controlled by the patient and often indicates peritoneal inflammation. Raising the knees and head as well as relaxing the patient can often decrease voluntary guarding.3 As previously mentioned, the patient’s arms should be at the side or crossed over the chest. The arms should not be rested above the head, as this will stretch and tighten the abdominal wall.6 Relaxation tech- niques, such as asking the patient to take a few deep breaths with the jaw dropped open6 or by attempting to distract the patient with conversation, may help the exam- iner determine whether the guarding is voluntary or involuntary. Deep palpation will follow superficial palpation and is necessary to assess the pres- ence of abdominal masses and to further assess the location, character, and quality of the pain. Palpation should again be performed with the palmar surfaces of the fingers throughout all four quadrants. Once masses are identified, their location should be noted, as well as their size, shape, consistency, tenderness, pulsations, and mobility.6 In patients with muscular resistance, obesity, or abdominal wall edema, deep palpa- tion is better accomplished using two hands. Usually, the dominant hand is placed on top of the nondominant hand, with the upper hand placing pressure and the lower hand focusing on palpation. Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved. 694 DiLeo Thomas & Henn While superficial palpation already identified the concerning areas of tenderness, with deep palpation, the examiner may be able to further localize the tenderness and determine if there is peritoneal irritation. The patient may have indicated that coughing or simply moving on the bed worsens the abdominal pain. If not, the exam- iner can ask the patient to cough, and if the cough produces pain in a specific location, this is likely an area of localized peritoneal irritation.6 The examiner can also now check for rebound tenderness. Rebound tenderness can be described as worsening pain on release of deep palpation. It results from movement of the inflamed peritoneum. It is performed by pressing the fingers into the region of concern slowly and firmly to depress the peritoneum for 15 to 30 seconds and then release the fingers quickly from the skin.9 The examiner should watch and listen closely for signs from the patient that this maneuver has elicited discomfort.6 A positive finding of rebound is estab- lished if the patient experiences discomfort when the fingers were released. The pa- tient should indicate where the pain was most intense during the examination. If tenderness was felt in a location other than where the examiner was palpating, that area may be the source of peritoneal irritation.6 Patients with diffuse peritonitis, which may occur in perforated viscus cases such as a perforated ulcer, perforated appendicitis, perforated diverticulitis, or even in patients with acute pancreatitis, will sometimes be described as having a “boardlike” or rigid abdomen.3 This is due to involuntary guarding that is present in these cases. Other- wise, the location of tenderness can usually help narrow the differential. In terms of gastrointestinal sources, right upper quadrant tenderness frequently indicates biliary disease, ulcer disease, hepatitis, or pancreatitis. Epigastric tenderness may indicate pancreatitis or peptic ulcer disease. Right lower quadrant tenderness may be due to acute appendicitis, perforated carcinoma, or cecal diverticulitis. Left lower quadrant tenderness is usually secondary to sigmoid diverticulitis. Palpation of the abdomen will also allow the examiner to determine other abnormal- ities such as crepitus of the abdominal wall, which indicates air in the subcutaneous tissue.4 Crepitus in the abdominal wall is introduced either by trauma or by infection from gas-producing bacteria.3 Digital Rectal Examination While classically the digital rectal examination (DRE) was considered to be a critical portion of the abdominal examination, the utility of the DRE is limited. DRE can be a useful screening tool in the setting of anorectal, urologic, or gynecologic pathology but does not provide diagnostic guidance in most intra-abdominal pathologies. Spe- cifically, the use of DRE to determine the need for surgical intervention in the setting of possible acute appendicitis has not proven to be accurate and may lead to inappro- priate surgical management.10 However, classic teaching is that the abdominal examination ends with the DRE. If the examiner determines that a DRE is indicated, the procedure will need to be thor- oughly explained to the patient, and consent should be obtained. With an appropriate chaperone, but still maintaining the patient’s privacy, a lubricated, gloved finger should be placed against the patient’s rectal sphincter muscle to relax it, then slowly moved into the rectum while palpating for any masses or foreign bodies.4 While pros- tatitis typically presents with urinary symptoms, it can be a cause of lower abdominal and, in particular, suprapubic pain.11 The examiner should palpate the prostate for tenderness or bogginess, which can indicate prostatitis.4 A rigorous digital prostate examination should be avoided in these patients as it can lead to systemic bacter- emia.11 After the finger is removed, the glove should be visually inspected for blood or melena.4 Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.  Perfecting the Abdominal Exam 695 Genitourinary Examination The utility of the pelvic examination in the evaluation of abdominal pain has been debated as studies cite few cases where the management plan changes based on the examination, and the examination itself can be unreliable.12,13 Often difficult to complete in the emergency department because of space and privacy restraints and found to be a poor test with low sensitivity,12 the pelvic examination has more recently been discussed as an unnecessary part of the examination of a patient with abdominal pain. However, although the pelvic examination can be an invasive ex- amination for your patient, there may be findings that can significantly impact the pa- tient’s management plan. One study examined the utility of pelvic examinations with the goal to look for adnexal tenderness, cervical motion tenderness, uterine tender- ness, uterine bleeding, discharge, and abnormalities of the cervical os and found that 6% (12/183 patients) had findings that were unexpected and changed the clinical plan.13 These aforementioned findings can suggest diagnoses associated with signif- icant morbidity and mortality including ovarian pathology, pelvic inflammatory dis- ease, uterine masses, cervicitis, and malignancies. Testicular examinations, searching to evaluate specifically for an abnormal testic- ular lie, high riding testicle, or absence of the cremasteric reflex, should be included in your examination of the male patient with abdominal pain to rapidly evaluate for testicular torsion.14 Skin changes on the ipsilateral scrotum may be present including induration, erythema, and warmth as an indicator of prolonged inflammation.15 An abnormal examination is only reported in 50% of patients with testicular torsion,14 but if torsion is suspected, surgical intervention should not be delayed for further im- aging diagnostics.15 If the diagnosis is unclear based on history and examination, then scrotal ultrasound with Doppler should follow immediately.15 SIGNS AND TESTS Table 1 shows the most common physical examination maneuvers as well as their respective sensitivities and specificities. Other tests, while commonly performed, have less robust data regarding their sensi- tivity and specificity in the evaluation of a patient with abdominal pain. These are listed in the following paragraphs. Caput Medusa In hepatic cirrhosis, inspection of the abdominal wall can reveal caput medusa, the descriptive term given to distended veins flowing away from the umbilicus.4 Carnett’s Sign Anterior cutaneous nerve entrapment is a case where abdominal pain can fool the examiner into thinking there may be a deeper, visceral cause of the pain. Carnett’s sign is used to differentiate between an intra-abdominal cause of pain versus abdom- inal wall pain. If this sign is present, straight leg raise or another maneuver that tenses the abdominal wall musculature will worsen the patient’s abdominal pain, or palpation of the area during this maneuver worsens it. This indicates that the pain is localized to the abdominal wall.18 Closed Eyes Sign Patients with an organic disease causing abdominal pain usually leave their eyes open while the examiner performs an abdominal examination, while those patients with nonspecific abdominal pain will close their eyes.19 Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.  696 Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved. DiLeo Thomas & Henn Table 1 Abdominal signs on physical examination16,17 Sign Disease Process Description Sensitivity Specificity Rovsing Acute appendicitis Pressing the hand deeply in the left lower quadrant results in pain at 19%–75% 58%–93% McBurney’s point. McBurney Acute appendicitis When applying pressure at McBurney’s point (1.5–2 inches from the anterior 83% 45% superior iliac spine on an imaginary line drawn to the umbilicus) with one finger, pain is elicited. Psoas Acute appendicitis The examiner asks the patient to lie on the opposite side (left) and extend 13%–42% 79%–97% the leg on the affected side (right). Extension of this leg will cause pain. The examiner may also place pressure against the patient’s knee while they attempt to raise it. Alternatively, the patient may also hold the hip in flexion to relieve pain. These maneuvers stretch the psoas muscle which is painful in an inflamed appendix but also can be painful in the setting of a psoas abscess, urologic, or paraspinal condition. Obturator Acute appendicitis The examiner stands on the right of the patient and slightly flexes the right 8% 94% thigh, to relax the psoas muscle. Then the limb is internally rotated at the hip. Test is positive if the patient complains of hypogastric pain with this movement. Murphy Acute cholecystitis The patient is unable to take a full inspiration while the examiner is 48%–97% 48%–96% palpating deeply underneath the costal margin in the right upper quadrant.  Perfecting the Abdominal Exam 697 Cullen’s Sign Cullen’s sign is periumbilical ecchymosis. This indicates intra-abdominal or retroper- itoneal hemorrhage.4 Grey Turner’s Sign In hemorrhagic pancreatitis, patients can develop ecchymosis of the flanks and groin known as Grey Turner’s sign.4 SPECIAL CONSIDERATIONS The Unstable Patient The obtunded, intubated, or otherwise critically ill patient is often unable to provide a thorough history. Unfortunately, the physical examination also lacks reliability in this clinical scenario, introducing the risk of diagnostic errors.20 The most common infectious etiology in critically ill patients is intra-abdominal pathology, but the physical examination only aids in the diagnosis 42% to 69% of the time in the setting of intra- abdominal abscess.20 While adjunct testing becomes critical to accurately diagnose possible intra-abdominal sources of the illness, many of these patients are not stable enough to undergo testing or imaging. Aggressive resuscitation is often needed, and the early administration of broad-spectrum antibiotics should be emphasized. While diagnostic imaging, most commonly computerized tomography, plays an important role in the evaluation of the critically ill patient, the physical examination directs the plan of care in choosing the correct imaging modality and location.20 Pediatric Population The pediatric population poses several diagnostic challenges because of the limited history based on the verbal development of the child, caregiver involvement, as well as the wide spectrum of pediatric-specific gastrointestinal diseases. Especially in the preverbal or young child, the caregivers may be the best source of historical infor- mation. The age of the child often determines the utility of the history in addressing the pediatric patient with abdominal pain. With a limited history, the examination becomes all the more critical in the evaluation of younger patients. The positioning of the child and introduction of the examiner in a nonthreatening way is the first step in eliciting reliable results from the examination.9 In talking with the patient first, allowing the child to remain in the caregiver’s lap, and starting with painless components of the exam- ination, the examiner will develop trust of the child and elicit a more reliable examina- tion.9 Distraction techniques of talking, using the stethoscope for palpation, or examining the abdomen during sleep can all be useful tools in examining the abdomen of an anxious pediatric patient.9 In addition to the aforementioned examination method of detecting rebound tenderness to indicate peritoneal inflammation, other maneuvers in children may be helpful. Asking the patient to jump up and down, bump- ing the bed, or tapping the feet may elicit discomfort in the abdomen consistent with peritoneal pain, similar to rebound tenderness.9 Elderly Population As our society ages, so does the emergency department patient population. Geriatric patients frequently require special attention as they are prone to worse outcomes, higher rates of hospital admission and surgical intervention, and longer emergency department (ED) and hospital stays than our younger patients.21 Elderly patients are more likely to present with diffuse and nonspecific pain and have a more subtle pre- sentation, and therefore, they will require a more time- and resource-intensive Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved. 698 DiLeo Thomas & Henn evaluation.22 There are several reasons why geriatric patients are unique. Physiologic changes occur to almost every organ system as the patient ages, and this can affect not just the patient’s presentation but also the response to interventions.22 Typical findings of rebound and guarding may be absent because of atrophy of abdominal wall musculature.21 Changes in the peripheral nervous system may change the perception of pain and may lead to a more subtle presentation and even a delay of the patient’s presentation to the ED. This patient population is more likely to be on medications that may interfere with or blunt the physical examination, such as ste- roids, beta-blockers, nonsteroidal anti-inflammatories, or opioids.21,22 In patients older than 80 years, mortality more than doubles if the diagnosis is missed21; there- fore, the examiner must remain cognizant of the limitations of the geriatric patient’s physical examination and maintain a high index of suspicion of significant intra- abdominal pathology. Pregnant Population This special patient population has a wide variety of anatomic and physiologic changes that occur during pregnancy and vary by gestational age, and determining the cause of acute abdominal pain in these patients can be difficult. After 12 weeks of gestation, the uterus becomes an abdominal organ and can begin to compress the abdominal viscera.23 The abdominal wall also becomes more lax which can delay findings of peritoneal signs.23 The most common reason for nonobstetric surgical intervention in pregnant patients is appendicitis, which affects 1 in 1500 pregnancies. Traditional teaching is that the ap- pendix rises in the peritoneal cavity as the uterus enlarges, beginning around 12 weeks, reaching the iliac crest around 24 weeks. However, more recently, this has been chal- lenged.23 A high clinical suspicion is necessary when evaluating these patients because morbidity is high. An unruptured appendix has a fetal mortality rate of 3% to 5%, while a ruptured appendix has a fetal mortality rate of 20% to 25% and 4% maternal mortality.23 These mortality rates are significant when compared to the overall mortality rate of appendicitis, which is 0.27% to 0.29% for unperforated and 1.18% for perforated. 24,25 Not only are peritoneal signs delayed in pregnant patients but the location and character of their tenderness also differ from those of the nonpregnant patient. Biliary disease is another cause of abdominal pain in pregnant patients as it is thought that the increase in sex steroids during pregnancy causes delayed gallbladder emptying. However, acute cholecystitis is not more common during pregnancy. Physical examina- tion findings of acute cholecystitis are similar to those in the nonpregnant patient with right upper quadrant tenderness and possibly a positive Murphy’s sign.23 Although the abdominal examination is a critical portion of the physical examination and reveals a great deal of pathology in the patient, there are limitations that may make the abdominal examination less reliable. Pregnancy can obscure landmarks, especially in later gestational ages. In addition to the anatomic changes in pregnancy, the decreased tone in abdominal wall muscles can decrease the ability to detect rebound tenderness. This change can also be seen in elderly patients. In addition, obesity, abdominal ascites, psychiatric disease, and intoxication can decrease the reliability of the abdominal exam- ination. Other chronic disease processes including diabetes and chemotherapy or steroid-induced immunosuppression can alter the examination findings. OTHER/ADJUNCTS TO THE ABDOMINAL EXAMINATION A complete evaluation of the patient should take place in addition to the abdominal examination described previously. These adjuncts to the abdominal examination Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.  Perfecting the Abdominal Exam 699 Table 2 Adjuncts to abdominal examination4 Location Finding Possible Disease Process Arms/hands Limbs Asterixis/tremor End-stage liver disease/alcohol withdrawal Arms Track marks (scarring over veins) Possible intravenous drug use (past or present) Limbs Dialysis fistula/graft End-stage renal disease Hands/feet Pallor Anemia Face/neck Eyes Scleral icterus End-stage liver disease Pallor of conjunctiva Anemia Kayser-Fleischer ring (due to Wilson’s disease excess deposition of copper) Xanthelasma (periorbital lipid Chronic cholestasis deposits) Mouth/oral cavity Oral ulcers Crohn’s disease, celiac disease Angular cheilitis Iron deficiency Red, beefy, smooth tongue Vitamin B-12, folate deficiency Fruity odor to breath Diabetic ketoacidosis Neck Virchow’s node (supraclavicular Gastric or breast cancer lymph node) can complete the clinical picture and give indicators to the pathology affecting the pa- tient. In Table 2, we describe specifics in the remainder of the examination and how it may correlate with abdominal pathology. CLINICAL CONTROVERSIES AND MYTHS Is it possible to detect an abdominal aortic aneurysm (AAA) on physical examination? Is it safe? AAAs are often asymptomatic and contribute to a significant number of potentially pre- ventable deaths in the United States yearly. Once ruptured, the AAA has a mortality rate of almost 50%.26 One cost-effective way to detect an AAA is by abdominal palpa- tion27 (Fig. 4). The palpation of an AAA to measure the width can be a highly sensitive way to evaluate for an AAA large enough to indicate the need for surgical intervention with a sensitivity of 72% of AAA measured at 4 cm or larger.27 However, body habitus can decrease that sensitivity (91% vs 53% sensitivity with abdominal girth >100 cm).26,27 This physical examination finding of a widened abdominal aorta should be followed by ultrasound to confirm the suspicions found during examina- tion.27 Although some may worry that it is possible to precipitate a rupture by palpating the aortic pulsation, this has never been reported. Therefore, palpation of the aneu- rysmal aorta appears to be safe.28 Will Giving Pain Medications Mask Important Findings? Although some may be hesitant to treat patients with pain medication lest it masks signs of a surgical abdomen. Specifically, classic teaching warns us that if patients are given pain medication, consultants, namely surgeons and radiologists, may not appreciate the same examination that the emergency medicine physician has Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved. 700 DiLeo Thomas & Henn Fig. 4. Inguinal hernia. Estimating an aortic aneurysm diameter as the distance between the closest fingers. (Beckman JA, Creager MA. Vascular Medicine: A Companion to Braunwald’s Heart Disease. 2020. Page 474-482.) obtained. Studies have indicated that this is not the case. Emergency medicine and surgical studies alike have demonstrated that the administration of analgesics does not impair the diagnostic accuracy of examination findings.29,30 In particular, the sono- graphic Murphy’s sign is not hindered by administration of opioid analgesia.31 SUMMARY Despite the increased use of adjunct imaging, the physical examination remains an informative and necessary part of patient care that gathers information critical to med- ical decision-making. Here, we have summarized the various components of the abdominal examination including inspection and exposure, percussion, auscultation, and palpation. When carried out correctly, the abdominal examination is a key diag- nostic tool and a window into the overall health and acute pathology of the patient. CLINICS CARE POINTS  The positioning of the patient is the key to a thorough and accurate examination. The examiner must take the time to explain the examination and place the patient in a comfortable position for a reliable and informative examination. Downloaded for Anonymous User (n/a) at University of Monterrey from ClinicalKey.com by Elsevier on January 09, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.  Perfecting the Abdominal Exam 701  A complete abdominal examination includes inspection, percussion, auscultation, palpation, as well as examination of the oral cavity, genitalia, and anus when appropriate.  Adjuncts to your abdominal examination can provide evidence of intra-abdominal pathologies including examination of the arms, hands, face, neck, and skin.  There are several signs that can be pathognomonic when examining the patient and that can immediately inform next steps in management.  Special populations including patients who are pregnant, critically ill, or at the extremes of age may harbor significant intra-abdominal pathologies despite an unremarkable examination. DISCLOSURE The authors have nothing to disclose. REFERENCES 1. Bilal M, Voin V, Topale N, et al. The clinical anatomy of the physical examination of the abdomen: a comprehensive review. Clin Anat 2017;30:352–6. 2. Macaluso C, McNamara R. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med 2012;5:789–97. 3. Ferguson CM. Inspection, auscultation, palpation, and percussion of the abdomen. In: Walker HK, Hall WD, Hurst JW, editors. Clinical methods: the his- tory, physical, and laboratory examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 93. 4. Mealie CA, Ali R, Manthey DE. Abdominal exam. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. Available at: https://www.ncbi.nlm.nih.gov/ books/NBK459220/. 5. 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