Performing The Abdominal Examination Assignment

An abdominal examination can give diagnostic clues regarding most gastrointestinal disease processes and may also give insight regarding abnormalities of other organ systems. A well-performed abdominal examination decreases the need for detailed radiological investigations.

PERFORMING THE ABDOMINAL EXAMINATION

The abdominal examination is performed with the patient lying supine. The examiner should begin by giving their formal introduction and then approach the patient and perform the examination from the right side of the patient. The initial steps are described as follows: Performing The Abdominal Examination Assignment

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1. Wash hands thoroughly with soap and water. An alcohol-based sanitizer can also be used. The examiner needs to ensure that their hands are dry and warm before starting the examination.
2. Identify the patient.
3. Briefly explain the reason for and the steps of the examination and take consent from the patient.
4. Inquire if the patient has any pain.
5. Position the patient. The patient is initially positioned at 45 degrees for comfort, but a supine position is necessary to palpate the abdomen. Keeping a pillow under the patient’s head or knees can be considered.
6. The ideal exposure is from the nipples to the knees, but this is sometimes not practically possible. During most clinical examinations, the exposure is from the nipples to the lower abdomen. Performing The Abdominal Examination Assignment

General Inspection

Begin with the general inspection of the patient and then proceed to the abdominal area. This should be performed at the foot end of the bed. The general inspection can give multiple clues regarding the patient’s diagnosis; for example, yellowish discoloration of the skin (jaundice) indicates a possible hepatic abnormality. It is important to note any medical equipment for monitoring and/or treatment attached to the patient or present in the bed space. These may include catheters, pulse oximeter, oxygen mask and tubing, nasogastric tube, central lines, and total parenteral nutrition lines.

The abdominal examination consists of four basic components: inspection, palpation, percussion, and auscultation.

Four Examination Components

Inspection of the Abdomen

It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders. Distension of the abdomen could be present due to small bowel obstruction, masses, tumors, cancer, hepatomegaly, splenomegaly, constipation, abdominal aortic aneurysm, and pregnancy. The presence of any abnormal masses may indicate umbilical hernia, ventral wall hernia, femoral hernia, or inguinal hernia, depending on the location. The patient may be asked to cough, which results in raised intraabdominal pressure, causing the hernia to become more prominent. Performing The Abdominal Examination Assignment

Auscultation of the Abdomen

The last step of the abdominal examination is auscultation with a stethoscope. The diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen to the bowel sounds, and their rate should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2 to 5/min. Absent bowel sounds may indicate paralytic ileus, and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes might be auscultated in lactose intolerance.

Percussion of the Abdomen

A proper technique of percussion is necessary to gain maximum information regarding abdominal pathology. While percussing, it is important to appreciate tympany over air-filled structures such as the stomach and dullness to percussion, which may be present due to an underlying mass or organomegaly (for example, hepatomegaly or splenomegaly). To appreciate splenic enlargement, the percussion of the Castell’s point (the most inferior interspace on the left anterior axillary line) as the patient takes a deep inspiration may be helpful. Performing The Abdominal Examination Assignment

Palpation of the Abdomen 

Ensure the following before beginning the palpation:

• The patient is in a supine position, with the head relaxed and the arms on the side of the body. This is necessary to relax the abdominal wall muscles completely.
• The patient has mentioned if he is experiencing any pain in the abdominal area and has located the point of maximal pain.

The ideal position for abdominal examination is to sit or kneel on the right side of the patient with the hand and forearm in the same horizontal plane as the patient’s abdomen. There are three stages of palpation that include superficial or light palpation, deep palpation, and organ palpation and should be performed in the same order. Maneuvers specific to certain diseases are also a part of abdominal palpation. Performing The Abdominal Examination Assignment

The examiner should begin with superficial or light palpation from the area furthest from the point of maximal pain and move systematically through the nine regions of the abdomen. If no pain is present, any starting point can be chosen. Several sources mention that the abdomen should first gently be examined with the fingertips. Crepitus, a crunching sensation, if present, indicates the presence of air in the subcutaneous tissue. Any irregularity in the abdominal wall may also be noted, which may be due to a hernia or a lipoma.

Deep palpation should be performed in the same position of the hand and forearm relative to the patient’s abdomen but with the application of firm and steady pressure. It is important to press slowly as pressing too fast may trap a gas pocket within the intestinal lumen and distend the wall resulting in false-positive tenderness. During palpation, tenderness should be noted, which may present as guarding. This may be a voluntary process, in which the patient voluntarily tightens the abdominal muscles to protect a deeper inflamed structure, or an involuntary process, where the intra-abdominal pathology has progressed to cause rigidity of the abdominal muscles. Engaging the patient in conversation may help differentiate between voluntary and involuntary guarding, as the former disappears when the patient’s attention is diverted. Tenderness in any of the nine regions of the abdomen may indicate an inflammation of the organ’s underneath. Performing The Abdominal Examination Assignment

Examination of the different areas of the abdomen may indicate separate disease processes. Tenderness of the epigastrium may be due to gastritis or early acute cholecystitis from visceral nerve irritation. Other signs that may be appreciated include the presence of a pulsatile mass from an abdominal aortic aneurysm or abdominal wall defects, seen in muscle diastasis. Left lower quadrant tenderness may be a presenting sign of diverticulitis in the elderly. A mass, if present, could be due to a tumor of the colon, a left ovarian cyst, or ectopic pregnancy. In the elderly, constipation leading to impacted feces may also present with a mass palpated in the left lower quadrant.

In the right lower quadrant, tenderness over McBurney’s point implies possible appendicitis, inflammation of the ileocolic area that may be due to Crohn disease, or an infection with bacteria that have a predilection for the ileocecal area such as Bacillus cereus and Yersinia enterocolitica. Performing The Abdominal Examination Assignment

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If tenderness is appreciated at McBurney’s point, the following maneuvers to identify possible appendicitis should be performed:

• Rovsing’s sign: While standing on the patient’s right side, gradually perform deep palpation of the left lower quadrant. Increased pain on the right suggests right-sided peritoneal irritation.
• Psoas sign: Place your hand just above the patient’s right knee and ask the patient to push up against your hand. This results in contraction of the psoas muscle, which causes pain if there is an underlying inflamed appendix.
• Obturator sign: This is performed by flexing the patient’s right thigh at the hip with the knee flexed and rotating internally. Increased pain at the right lower quadrant suggests inflammation of the internal obturator muscle from overlying appendicitis or an abscess.

Review the case study noted below:
Answer the questions for each case.
Case 1: Male with Abdominal Pain Performing The Abdominal Examination Assignment

The patient is a 32-year-old male with no significant past medical history presents to the emergency department with abdominal pain. He states the pain began a few days ago in the right lower quadrant of the abdomen, and now feels as though it is spreading to the mid-abdomen. He describes the pain as coming on suddenly and sharp in nature. Since onset, his pain started to improve until the morning of presentation to the emergency department when it acutely worsened. He says that the pain is much worse with movement.

The patient is concerned for a possible hernia as he does heavy lifting at work. Review of systems is negative including no anorexia, no nausea or vomiting, no testicular pain or swelling, no urinary or bowel complaints, and no fevers or chills. The patient denies prior abdominal surgeries. He does smoke a half pack of cigarettes a day, drinks alcohol socially, and denies any recreational drug use. He notes no inherited medical conditions in his family. Performing The Abdominal Examination Assignment

How will you conduct a focused assessment of this patient? What systems would you examine during this focused assessment?Do not forget that your exam has to be done in a systematic way. Think Inspection, Palpation, Percussion, and Auscultation – (if indicated) when submitting
What initial tests need to be conducted and why? Performing The Abdominal Examination Assignment