Lecture Notes

Assessing the Abdomen

A.

purposes I. to determine changes in the internal environment of the body II. to yield valuable information on general health status III. to provide information needed to identify specific systemic diseases IV. to determine the health status of the gastrointestinal and genitourinary systems and the presence of specific vascular abnormalities B. structure and function function a. the gastrointestinal and genitourinary system I. structure . for descriptive purposes, the abdomen is divided into four quadrants by imaginary lines crossing at the umbilicus i. right lower quadrant a. lower pole of the right kidney b. cecum c. appendix d. portion of the ascending colon e. right ovary and fallopian tube f. right spermatic cord g. right ureter ii. right upper quadrant . liver a. gallbladder b. pyloric spinchter c. duodenum d. head of the pancreas e. right adrenal gland f. portion of the right kidney g. hepatic flexure of the colon h. portions of the ascending and transverse colon iii. left upper quadrant . left left of the liver a. spleen b. stomach c. body of the pancreas d. left adrenal gland e. portion of the left kidney f. splenic flexure of the colon g. portions of the transverse and descending colon iv. left lower quadrant

lower pole of the left kidney a. sigmoid colon b. portion of the descending colon c. sigmoid colon d. left ovary and fallopian tube e. left spermatic cord f. left ureter C. pertinent history

adults

appetite

dysphagia food intolerance abdominal pain nausea/vomiting change in bowel habits change in weight increasing abdominal girth past abdominal history medications self-care behaviors usual state of health I. additional history for infants and children . baby breath or bottle fed a. what table foods have been introduced b. frequency of eating c. constipation d. abdominal pain e. how long obesity has been a problem if weight if greater than body requirements II. additional history for adolescents . food eaten at regular meals a. exercise pattern b. amount of weight lost is weight is less than body requirements III. additional history for the aging adult . how groceries are acquired and how meals are prepared a. does the person eat alone or with other people b. what the patient had to eat yesterday, starting with breakfast c. frequency of bowel movements D. health promotion and screening test Interval . beginning at Age 50, both men and women should follow one of the 5 screening options: . FOBT annually and flexible sigmoidoscopy every 5 years . all positive tests should be followed up with a colonoscopy i. flexible Sigmoidoscopy every 5 years . all positive tests should be followed up with a colonoscopy ii. FOBT yearly . all positive tests should be followed up with a colonoscopy iii. colonoscopy every 10 years

a. b. c. d. e. f. g. h. i. j. k.

colonoscopy provides an opportunity to visualize, sample, and/or remove significant lesions iv. double-contrast barium enema (DCBE) every 5 years . all positive tests should be followed up with a colonoscopy I. the following risk factors require colon cancer screening to begin at an earlier age or more frequently: cancer or polyps in a first-degree relative younger than 60 or in two first-degree relative of any age, e.g.: . a parent, sibling, or child a. a known family history of hereditary colorectal cancer syndromes, e.g.: . familial adenomatous polyposis i. hereditary non-polyposis colon cancer b. a personal history of colorectal cancer or adenomatous polyps c. a personal history of chronic inflammatory bowel disease, e.g.: . ulcerative colitis i. Chron's disease E. preparation of the patient and environment

patient greet the patient and establish rapport a. explain the procedure to the patient in simple terms what will be done, what he/she should expect, and how he/she can cooperate during the examination b. assist the patient in assuming a position of lying supine on an examining table with his/her head on a small pillow and his/her arms at his/her sides c. encourage the patient to ask questions and mention any discomfort he/she feels during the examination I. environment . private a. adequately lit b. warm c. quiet F. techniques of examination inspect the skin over the abdomen . observe the skin over the abdomen from all angles a. normal findings: . skin intact, similar in color to the rest of the body, smooth, and uniform i. silver-white striae ii. barely visible, flat venous pattern b. deviations from normal findings: . scars i. purple striae ii. prominent, dilated veins iii. rashes iv. lesions v. cutaneous angiomas (spider nevi) . e.g., portal hypertension, liver disease vi. poor turgor vii. redness viii. jaundice ix. skin taut, glistening

e.g., ascites I. inspect the umbilicus of the abdomen observe the umbilicus of the abdomen from all angles a. normal findings: . midline position i. inverted ii. slightly elevated b. deviations from normal findings: . deviated from midline position i. markedly inverted ii. markedly everted . e.g., umbilical hernia iii. blue . e.g., Cullen's sign; intra-abdominal hemorrhage iv. discolored v. inflammation vi. drainage II. inspect the contour (shape) of the abdomen observe the contour (shape) of the abdomen, by: . standing at the right side of the patient i. looking down from above on the patient's abdominal profile from his/her costal margins to his/her symphysis pubis from all angles ii. observing the patient's abdominal profile from all angles iii. stooping or kneeling iv. looking across the patient's abdominal profile v. observing the patient's abdominal profile from his/her costal margins to his/her symphysis pubis from all angles a. normal findings: . flat . an abdominal contour in which a horizontal line remains straight from the costal margins to the symphysis pubis i. rounded . an abdominal contour in which a horizontal line curves outward, typically in either the upper, middle, or lower half of the abdomen ii. scaphoid . an abdominal contour in which a horizontal line curves inward, typically in the lower half of the abdomen iii. protruberant . an abdominal contour in which a horizontal line curves outward in the upper, middle, and lower half of the abdomen b. deviations from normal findings: . bulging flanks . e.g., ascites i. suprapubic bulge . e.g., distended bladder, pregnant uterus ii. enlarged liver or spleen iii. localized bulges or masses III. inspect the abdomen for symmetry, bulges, or masses observe the abdomen for symmetry, bulges, or masses, by:

standing at the right side of the patient i. looking down from above on the patient's abdominal profile from his/her costal margins to his/her symphysis pubis from all angles ii. observing the patient's abdominal profile from all angles iii. stooping or kneeling iv. looking across the patient's abdominal profile v. observing the patient's abdominal profile from his/her costal margins to his/her symphysis pubis from all angles a. normal findings: . absence of bulges or masses b. deviations from normal findings: . presence of bulges or masses IV. inspect the abdomen for pulsations and/or movements observe the abdomen for pulsations and/or movements, by: . standing on the right side of the patient i. observing the patient's abdomen for pulsations and/or movements from all angles a. normal findings: . absence of pulsations or peristalsis in patient's who are normal weight, obese, or have poor abdominal wall relaxation i. aortic pulsations below the xyphoid process in patients who are thin or have good abdominal muscle wall relaxation ii. peristalsis in patients who are thin or have good abdominal muscle wall relaxation b. deviations from normal findings: . marked aortic pulsations below the xyphoid process i. marked peristalsis V. auscultate the abdomen auscultate the abdomen, by: . gathering a stethoscope i. standing on the right side of the patient ii. placing the diaphragm of your stethoscope over the right lower quadrant (RLQ) of the patient's abdomen iii. listening to the patient's bowel sounds in his/her RLQ for at least 1 minute iv. placing the diaphragm of your stethoscope over the right upper quadrant (RUQ) of the patient's abdomen v. listening to the patient's bowel sounds in his/her RUQ for at least 1 minute vi. placing the diaphragm of your stethoscope over the left upper quadrant (LUQ) of the patient's abdomen vii. listening to the patient's bowel sounds in his/her LUQ for at least 1 minute viii. placing the diaphragm of your stethoscope over the left lower quadrant (LLQ) of the patient's abdomen ix. listening to the patient's bowel sounds in his/her LLQ for at least 1 minute a. normal findings: . 5 - 30 bowel sounds per minute i. normal high-pitched clicks ii. normal gurgling quality

iii. normal cascading quality iv. borborygmous b. deviations from normal findings:
bowel sounds less than 5 per minute . e.g., hypoactive bowel sounds (high-pitched, rushing, tinkling) i. bowel sounds more than 30 per minutes . e.g., hyperactive bowel sounds ii. absent bowel sounds . e.g., no bowel sounds after auscultating all four quadrants for at least 5 minutes VI. auscultate the abdomen for bruits auscultate the abdomen for bruits, by: . standing at the right side of the patient i. placing the bell of your stethoscope in the umbilical quadrant of the patient's abdomen, in the area superior and slightly to the left of midline of his/her umbilicus ii. listening for a blowing, swishing sound (AORTA) iii. placing the bell of your stethoscope in the umbilical quadrant of the patient's abdomen, in the area superior and right of his/her umbilicus iv. listening for a blowing, swishing sound (RIGHT RENAL ARTERY) v. placing the bell of your stethoscope in the umbilical quadrant of the patient's abdomen, in the area superior and left of his/her umbilicus vi. listening for a blowing, swishing sound (LEFT RENAL ARTERY) vii. placing the bell of your stethoscope in the hypogastric (pubic) quadrant of the patient's abdomen, in the area inferior and right of his/her umbilicus viii. listening for a blowing, swishing sound (RIGHT ILIAC ARTERY) ix. placing the bell of your stethoscope in the hypogastric (pubic) quadrant of the patient's abdomen, in the arleft of his/her umbilicus x. listening for a blowing, swishing sound (LEFT ILIAC ARTERY) xi. placing the bell of your stethoscope in the right inquinal quadrant of the patient's abdomen, in the area of his/her right inquinal ligament about midway between the anterior superior iliac spine and symphysis pubis xii. listening for a blowing, swishing sound (RIGHT FEMORAL ARTERY) xiii. placing the bell of your stethoscope in the left inquinal quadrant of the patient's abdomen, in the area of his/her left inquinal ligament about midway between the anterior superior iliac spine and symphysis pubis xiv. listening for a blowing, swishing sound (LEFT FEMORAL ARTERY) a. normal findings: . absence of a blowing, swishing sound b. deviations from normal findings: . presence of a blowing, swishing sound VII. auscultate the abdomen for a friction rub over the liver auscultate the abdomen for a friction rub over the liver, by: . standing on the right side of the patient i. placing the bell of your stethoscope over the RUQ of the patient's abdomen in the right midclavicular line (RMCL) ii. listening for a harsh, coarse, rough, grating sound over the liver a. normal findings: . absence of a harsh, coarse, rough, grating sound over the liver

b. deviations from normal findings:

presence of a harsh, coarse, rough, grating sound over the liver . e.g., abcess, tumor VIII. auscultate the abdomen for a friction rub over the spleen auscultate the abdomen for a friction rub over the spleen, by: . standing on the right side of the patient i. placing the bell of your stethoscope over the LUQ of the patient's abdomen in the left anterior axillary line (LAAL) ii. listening for a harsh, coarse, rough, grating sound over the spleen a. normal findings: . absence of a harsh, coarse, rough, grating sound over the spleen b. deviations from normal findings: . presence of a harsh, coarse, rough, grating sound over the spleen . abcess, tumor, infection IX. percuss the abdomen for prevailing tympany and dullness percuss the abdomen for prevailing tympany and dullness, by: . standing on the right side of the patient i. placing your hands in the correct position for percussion over the RLQ of the patient's abdomen ii. percussing the RLQ of the patient's abdomen in at least three separate areas iii. listening for the percussion notes obtained during percussion over the RLQ of the patient's abdomen iv. placing your hands in the correct position for percussion over the RUQ of the patient's abdomen v. percussing the RUQ of the patient's abdomen in at least three separate areas vi. listening for the percussion notes obtained during percussion over the RUQ of the patient's abdomen vii. placing your hands in the correct position for percussion over the LUQ of the patient's abdomen viii. percussing the LUQ of the patient's abdomen in at least three separate areas ix. listening for the percussion notes obtained during percussion over the LUQ of the patient's abdomen x. placing your hands in the correct position for percussion over the LLQ of the patient's abdomen xi. percussing the LLQ of the patient's abdomen in at least three separate areas xii. listening for the percussion notes obtained during percussion over the LLQ of the patient's abdomen a. normal findings: . RLQ . predominance of tympany i. RUQ . predominance of tympany a. dullness over the liver in the RUQ ii. LUG . predominance of tympany a. tympany over the gastric air bubble in the LUQ

. .
RLQ

LLQ predominance of tympany in the LLQ b. deviations from normal findings:

iii.

predominance of dullness a. dullness over a(n) distended bladder, adipose tissue, feces in the colon, mass, gravid uterus i. RUQ . predominance of dullness a. dullness over adipose tissue or a mass ii. LUQ . predominance of dullness a. dullness over adipose tissue or a mass iii. LLQ . predominance of dullness a. dullness over a(n) distended bladder, adipose tissue, feces in the colon, mass, gravid uterus X. percuss the abdomen to determine the vertical span or height of the liver percuss the abdomen to determine the vertical span or height of the liver, by: . standing on the right side of the patient i. placing your hands in the correct position for percussion in the right midclavicular line (RMCL) of the RLQ of the patient's abdomen ii. percussing on a point in the RMCL in the RLQ of the patient's abdomen in an area of abdominal tympany, not dullness iii. percussing upward in the RMCL of the RLQ of the patient's abdomen in progressive steps, in the area of abdominal tympany not dullness, to the lower border of liver dullness iv. marking the lower border of liver dullness with a skin marking pen v. placing your hands in the correct position for percussion in the RMCL below the clavicle of the the patient's right upper chest vi. percussing on a point in the RMCL below the clavicle of the patient's right upper chest in an area of lung resonance, not dullness vii. percussing downward in the RMCL below the clavicle of the patient's right upper chest in progressive steps, in the area of lung resonance not dullness, to the upper border of liver dullness viii. marking the upper border of liver dullness with a skin marking pen ix. measuring the distance between the two skin marking pen points a. normal findings: . normal vertical span of the liver in the RMCL . e.g., 5 - 10 centimeters (2 - 4 inches) i. normal vertical span of the liver in the midsternal line . e.g., 4 - 8 centimeters (1 1/2 - 3 inches) b. deviations from normal findings: . abnormal vertical span of the liver in the RMCL . e.g., greater than 10 centimeters (4 inches) (hepatomegaly) i. abnormal vertical span of the liver in the midsternal line . e.g., greater than 8 centimeters (3 inches) (hepatomegaly) ii. normal vertical span of the liver displaced downward by lung disease

e.g.: COLD, emphysema, pleural effusion iii. normal vertical span of the liver displaced upward . e.g., ascites, pregnancy, gaseous distention in the colon, a mass XI. perform the scratch test to determine the lower border of liver dullness (when the abdomen is distended or the abdominal muscles are tense) perform the scratch test to determine the lower border of liver dullness (when the abdomen is distended or the abdominal muscles are tense), by: . standing of the right side of the patient i. placing the diaphragm of of your stethoscope in the RMCL over the RUQ of the patient's abdomen ii. scratching the skin upward in the RMCL of the RLQ of the patient's abdomen with one finger iii. listening for the magnification of the scratching sounds in your stethoscope iv. marking the patient's abdomen with a skin marking pen when magnification of the scratching sounds is auscultated a. normal findings: . magnification of the scratching sounds in the stethoscope at or near the right costal margin b. deviations from normal findings: . magnification of the scratching sounds in the stethoscope below the right costal margin XII. percuss the liver for tenderness (if the liver is unpalpable) percuss the liver for tenderness (if the liver is unpalpable), by: . standing of the right side of the patient i. placing the palm of your left hand over the LUQ of the patient's abdomen ii. making a fist with your right hand iii. thumping the ulnar edge of your fisted right hand on the dorsal (top) surface of your left hand that is lying on the LUQ of the patient's abdomen iv. asking the patient if the maneuver elicited pain v. placing the palm of your left hand over the RUQ of the patient's abdomen vi. making a fist with your right hand vii. thumping the ulnar edge of your fisted right hand on the dorsal (top) surface of your left hand that is lying on the RUQ of the patient's abdomen viii. asking the patient if the maneuver elicited pain a. normal findings: . absence of pain elicited upon thumping the RUQ b. deviations from normal findings: . presence of pain elicited upon thumping the RUQ XIII. percuss the abdomen for splenic dullness percuss the abdomen for splenic dullness, by: . standing of the right side of the patient i. placing your hands in the correct position for percussion on the 9th intercostal interspace just posterior to the left midaxillary line (LMAL) of the patient's abdomen ii. percussing from the 9th interspace just posterior to the LMAL of the patient's abdomen

listening for the percussion notes obtained during percussion over the 9th interspace just posterior to the LMAL of the patient's abdomen iv. placing your hands in the correct position for percussion on the 10th intercostal interspace just posterior to the left midaxillary line (LMAL) of the patient's abdomen v. percussing from the 10th interspace just posterior to the LMAL of the patient's abdomen vi. listening for the percussion notes obtained during percussion over the 10th interspace just posterior to the LMAL of the patient's abdomen vii. placing your hands in the correct position for percussion on the 11th intercostal interspace just posterior to the left midaxillary line (LMAL) of the patient's abdomen viii. percussing from the 11th interspace just posterior to the LMAL of the patient's abdomen ix. listening for the percussion notes obtained during percussion over the 11th interspace just posterior to the LMAL of the patient's abdomen a. normal findings: . absence of splenic dullness i. splenic dullness less than 7 centimeters (2 3/4 inches) . e.g., splenomegaly, mononucleosis, trauma, infection ii. splenic dullness does not encroach on the normal tympany over the gastric air bubble b. deviations from normal findings: . splenic dullness greater than 7 centimeters (2 3/4 inches) i. splenic dullness encroaches on the normal tympany over the gastric air bubble XIV. percuss the abdomen for the splenic percussion sign (if splenomegaly is suspected) percuss the abdomen for the splenic percussion sign (if splenomegaly is suspected), by: . standing of the right side of the patient i. placing your hands in the correct position for percussion on the lowest interspace in the left anterior axillary line (LAAL) of the patient's abdomen ii. percussing the lowest interspace in the LAAL of the patient's abdomen iii. instructing the patient to take a deep breath iv. percussing the lowest interspace in the LAAL of the patient's abdomen again a. normal findings: . absence of a change in the percussion note from tympany to dullness during inspiration (negative splenic percussion sign) b. deviations from normal findings: . presence of a change in the percussion note from tympany to dullness during inspiration (postive splenic percussion sign) XV. lightly palpate the abdomen lightly palpate the abdomen, by: . standing of the right side of the patient i. placing the pads of the first four fingers of your right hand low and parallel to the RLQ of the patient's abdomen ii. pressing the pads of the first four fingers of your right hand 1 centimeter (1/2 inch) into the RLQ of the patient's abdomen

iii.

moving the pads of the first four fingers of your right hand in a circle over the RLQ of the patient's abdomen iv. placing the pads of the first four fingers of your right hand low and parallel to the RUQ of the patient's abdomen v. pressing the pads of the first four fingers of your right hand 1 centimeter (1/2 inch) into the RUQ of the patient's abdomen vi. moving the pads of the first four fingers of your right hand in a circle over the RUQ of the patient's abdomen vii. placing the pads of the first four fingers of your right hand low and parallel to the LUQ of the patient's abdomen viii. pressing the pads of the first four fingers of your right hand 1 centimeter (1/2 inch) into the LUQ of the patient's abdomen ix. moving the pads of the first four fingers of your right hand in a circle over the LUQ of the patient's abdomen x. placing the pads of the first four fingers of your right hand low and parallel to the LLQ of the patient's abdomen xi. pressing the pads of the first four fingers of your right hand 1 centimeter (1/2 inch) into the LLQ of the patient's abdomen xii. moving the pads of the first four fingers of your right hand in a circle over the LLQ of the patient's abdomen a. normal findings: . nontender i. soft ii. smooth iii. voluntary rigidity . abdominal muscle rigidity that occurs when a patient is cold, tense, or ticklish which usually relaxes during exhalation b. deviations from normal findings: . tenderness i. muscle gaurding ii. involuntary rigidity . constant, boardlike hardness of the abdominal muscles that accompanies acute inflammation of the peritoneum (e.g., peritonitis, appendicitis) iii. superficial masses XVI. deeply palpate the abdomen deeply palpate the abdomen, by: . standing on the right side of the patient i. placing the pads of the first four fingers of your right hand low and parallel to the RLQ of the patient's abdomen ii. pressing the pads of the first four fingers of your right hand 5 - 8 centimeters (2 - 3 inches) into the RLQ of the patient's abdomen iii. moving the pads of the first four fingers of your right hand in a circle over the RLQ of the patient's abdomen iv. placing the pads of the first four fingers of your right hand low and parallel to the RUQ of the patient's abdomen v. pressing the pads of the first four fingers of your right hand 5 - 8 centimeters (2 - 3 inches) into the RUQ of the patient's abdomen vi. moving the pads of the first four fingers of your right hand in a circle over the RUQ of the patient's abdomen

iii.

placing the pads of the first four fingers of your right hand low and parallel to the LUQ of the patient's abdomen viii. pressing the pads of the first four fingers of your right hand 5 - 8 centimeters (2 - 3 inches) into the LUQ of the patient's abdomen ix. moving the pads of the first four fingers of your right hand in a circle over the LUQ of the patient's abdomen x. placing the pads of the first four fingers of your right hand low and parallel to the LLQ of the patient's abdomen xi. pressing the pads of the first four fingers of your right hand 5 - 8 centimeters (2 - 3 inches) into the LLQ of the patient's abdomen xii. moving the pads of the first four fingers of your right hand in a circle over the LLQ of the patient's abdomen a. normal findings: . nontender i. soft ii. smooth iii. voluntary rigidity . abdominal muscle rigidity that occurs when a patient is cold, tense, or ticklish which usually relaxes during exhalation b. deviations from normal findings: . tenderness i. muscle guarding ii. involuntary rigidity . constant, boardlike hardness of the abdominal muscles that accompanies acute inflammation of the peritoneum (e.g., peritonitis, appendicitis) iii. masses XVII. palpate the abdomen for rebound tenderness (Blumberg's Sign) palpate the abdomen for rebound tenderness (Blumberg's Sign), by: . standing on the right side of the patient i. holding the pads of the fingers of your right hand at a 90 degree angle (perpendicular) to the patient's abdominal wall in a site away from the tender area ii. depressing the pads of the fingers of your right hand gradually and gently into the patient's abdomen iii. withdrawing the pads of the fingers of your right hand quickly from the patient's abdomen iv. asking the patient whether the depression or withdrawal of the pads of the fingers of your right hand from his/her abdomen elicited pain a. normal findings: . absence of pain elicited upon the quick withdrawal of the pads of the fingers . e.g., negative Blumberg's sign b. deviations from normal findings: . presence of pain elicited upon the quick withdrawal of the pads of the fingers . e.g., positive Blumberg's sign XVIII. palpate the liver palpate the liver, by: . standing on the right side of the patient i. placing your left hand under the 11th or 12th rib of the patient's right posterior thorax

vii.

lifting up the patient's right posterior thorax with your left hand to support the abdominal contents iii. placing the pads of the fingers of your right hand on the RMCL of the RUQ of the patient's abdomen pointing toward his/her right costal margin and below the edge of liver dullness iv. gradually and gently deeply pressing the pads of the fingers of your right hand on the RMCL of the RUQ of the patient's abdomen down and forward under his/her right costal margin v. instructing the patient to take a deep breath vi. feeling the liver border as it moves against the pads of the fingers of your right hand on the RMCL of the RUQ of the patient's abdomen below his/her right costal margin a. normal findings: . nontender i. smooth, firm, sharp liver edges b. deviations from normal findings: . tenderness i. irregular ii. enlarged XIX. palpate the spleen palpate the spleen, by: . standing on the right side of the patient i. reaching your left hand over the left side of the patient's abdomen and placing it under the 11th and 12th ribs of the his/her left posterior thorax ii. lifting up the patient's left posterior thorax with your left hand to support the abdominal contents iii. placing the pads of the fingers of your right hand obliquely on the LMCL of the LUQ of the patient's abdomen pointing toward his/her left costal margin, but just slightly distal to his/her left costal margin iv. gradually and gently deeply pressing the pads of the fingers of your right hand obliquely placed on the LMCL of the LUQ of the patient's abdomen that are pointing toward his/her left costal margin, but just distal to his/her left costal margin, down and forward under his/her left costal margin v. instructing the patient to take a deep breath vi. feeling the spleen as it moves against the pads of the fingers of your right hand obliquely placed on the LMCL of the LUQ of the patient's abdomen that are pointing toward his/her left costal margin, but just distal to his/her left costal margin, below his/her left costal margin a. normal findings: . usually not palpable i. nontender if palpable ii. absence of masses if palpable b. deviations from normal findings: . enlarged and easily palpable . e.g., splenomegaly i. tenderness ii. masses XX. palpate the right kidney palpate the right kidney, by: . standing on the right side of the patient

ii.

placing your left hand behind the 12th rib of the patient's right posterior thorax ii. lifting up the patient's right posterior thorax with your left hand to support the abdominal contents iii. placing the pads of the fingers of your right hand obliquely on the RMCL of the patient's RUQ of his/her abdomen pointing toward the patient's right costal margin, but just slightly distal to his/her right costal margin iv. gradually and deeply pressing the pads of the fingers of your right hand that are obliquely placed on the RMCL of the RUQ of the patient's abdomen that are pointing toward his/her right costal margin, but just slighly distal to his/her right costal margin, down and forward under his/her right costal margin v. feeling the pole of the right kidney as it moves against the pads of the fingers that are obliquely placed on the RMCL of the RUQ of the patient's abdomen that are pointing toward his/her right costal margin, but just slightly distal to his/her right costal margin, below his/her right costal margin a. normal findings: . usually not palpable i. nontender if palpable ii. absence of masses if palpable b. deviations from normal findings: . enlarged and easily palpable i. tenderness ii. masses XXI. palpate the left kidney palpate the left kidney, by: . standing on the right side of the patient i. reaching your left hand over the left side of the patient's abdomen and placing it under the 12th rib of the his/her left posterior thorax ii. lifting up the patient's left posterior thorax with your left hand to support the abdominal contents iii. placing the pads of the fingers of your right hand obliquely on the LMCL of the LUQ of the patient's abdomen pointing toward his/her left costal margin, but just slightly distal to his/her left costal margin iv. gradually and gently deeply pressing the pads of the fingers of your right hand that are obliquely placed on the LMCL of the LUQ of the patient's abdomen pointing toward his/her left costal margin, but slightly distal to his/her left costal margin, hand, down and forward under his/her left costal margin v. instructing the patient to take a deep breath vi. feeling the left kidney as it moves against the pads of the fingers of your right hand that are obliquely placed on the LMCL of the LUQ of the patient's abdomen pointing toward his/her left costal margin, but slightly distal to his/her left costal margin, below his/her left costal margin a. normal findings: . usually not palpable i. nontender if palpable ii. absence of masses if palpable b. deviations from normal findings: . enlarged and easily palpable

i.

tenderness masses palpate the aorta palpate the aorta, by: . standing on the right side of the patient i. placing the pads of the fingers of your right hand slightly to the left of midline below the zyphoid process of the patient's abdomen ii. placing the pads of the fingers of your left hand slightly to the right of midline below the xyphoid process of the patient's abdomen, close to the pads of the fingers of your right hand iii. gradually and deeply pressing the pads of the fingers of your right and left hands placed slighty to the left and right of midline below the xyphoid process of the patient's abdomen into his/her abdomen a. normal findings: . normal aortic width . e.g., 3 centimeters (1 inch) b. deviations from normal findings: . abnormally large aortic width . e.g., greater than 3 centimeters (1 inch) (abdominal aortic aneurysm) XXIII. test for Rovsing's sign (if appendicitis is suspected) test for Rovsing's sign (if appendicitis is suspected) by: . standing on the right side of the patient i. holding the fingers of your right hand at a 90 degree angle (perpendicular) to the patient's abdominal wall in the LLQ of the his/her abdomen ii. depressing the pads of the fingers of your right hand gradually and gently into the LLQ of the patient's abdomen iii. withdrawing the pads of the fingers of your right hand quickly from the LLQ of the patient's abdomen iv. asking the patient where he/she experienced pain, if present a. normal findings: . absence of pain in the RLQ b. deviations from normal findings: . presence of pain in the RLQ . e.g., appendicitis XXIV. perform the iliospoas muscle test (if appendicitis is suspected) perform the iliospoas muscle test (if appendicitis is suspected) by: . standing on the right side of the patient i. instructing the patient to lift his/her right leg straight up ii. pushing down on the thigh of the patient's right leg with your right hand iii. asking the patient to try to hold his/her right leg up against the resistance of your right hand iv. asking the patient where he/she experienced pain, if present a. normal findings: . absence of pain in the RLQ b. deviations from normal findings: . presence of pain in the RLQ . e.g., appendicitis XXV. perform the obturator test (if appendicitis is suspected) perform the obturator test (if appendicitis is suspected) by:

i. ii. XXII.

standing on the right side of the patient i. flexing the patient's right leg 90 degrees at the hip and knee ii. rotating the patient's right leg internally at his/her right hip iii. rotating the patient's right leg externally at his/her right hip iv. asking the patient where he/she experienced pain, if present a. normal findings: . absence of pain in the RLQ b. deviations from normal findings: . presence of pain in the RLQ . e.g., appendicitis XXVI. test for tenderness in the costovertebral angle test for tenderness in the costovertebral angle, by: . having the patient sit up and dangle his/her legs over the edges of an examining table i. standing on the right side of the patient ii. placing the palm of your left hand over the patient's 12th rib at the costovertebral angle of the right side of his/her posterior thorax iii. making a fist with your right hand iv. thumping the dorsal (top) surface of your left hand with the ulnar surface of your fisted right hand v. asking the patient if he/she experienced pain, if present vi. standing on the left side of the patient vii. placing the palm of your right hand over the patient's 12th rib at the costovertebral angle of the left side of his/her posterior thorax viii. making a fist with your left hand ix. thumping the dorsal (top) surface of your right hand with the ulnar surface of your fisted left hand x. asking the patient if he/she experienced pain, if present a. normal findings: . absence pain elicited upon thumping the CVA b. deviations from normal findings: . presence of pain elicited upon thumping the CVA XXVII. test for inspiratory arrest (Murphy's sign) (if acute cholecystitis is suspected) test for Murphy's sign (if acute cholecystitis is suspected), by: . standing on the right side of the patient i. placing your left hand under the 11th or 12th rib of the patient's right posterior thorax ii. lifting up the patient's right posterior thorax with your left hand to support the abdominal contents iii. placing the pads of the fingers of your right hand on the RMCL of the RUQ of the patient's abdomen pointing toward his/her right costal margin and below the edge of liver dullness iv. gradually and gently deeply pressing the pads of the fingers of your right hand on the RMCL of the RUQ of the patient's abdomen down and forward under his/her right costal margin v. instructing the patient to take a deep breath vi. observing the patient's breathing pattern a. normal findings: . absence of pain elicited upon inspiration

absence of an abrupt stop midway during inspiration (negative Murphy's sign) b. deviations from normal findings: . presence of pain elicited upon inspiration i. presence of an abrupt stop midway during inspiration (positive Murphy's sign) . e.g., cholecystitis XXVIII. test for a fluid wave (if ascites is suspected) test for a fluid wave (if ascites is suspected), by: . standing on the right side of the patient i. placing the ulnar edge of another examiner's or the patient's right hand firmly on the midline of the patient's abdomen ii. placing your left hand on the right flank of the patient's abdomen iii. reaching your right hand across and placing it on the left flank of the patient's abdomen iv. tapping the left flank of the patient's abdomen firmly with your right hand v. observing the patient's abdomen for a fluid wave vi. feeling for a distinct tap on your left hand a. normal findings: . absence of a fluid wave through the abdomen that is felt as a distinct tap on your left hand b. deviations from normal findings: . presence of a fluid wave through the abdomen that is felt as a distinct tap on your left hand . e.g., ascites XXIX. percuss for shifting dullness (if ascites is suspected) percuss for shifting dullness (if ascites is suspected), by: . standing on the right side of the patient i. placing your hands in the correct position for percussion over the RLQ of the patient's abdomen ii. percussing the RLQ of the patient's abdomen in an area of abdominal tympany, not fluid dullness iii. percussing down the RLQ of the patient's abdomen toward the right flank in the area of abdominal tympany to fluid dullness iv. marking the spot on the patient's right flank where your percussion note changed from abdominal tympany to fluid dullness v. assisting the patient to roll on his/her right side toward you vi. placing your hands in the correct position for percussion over and percussing over the RLQ of the patient's abdomen in an area of abdominal tympany, not dullness vii. percussing down the RLQ of the patient's abdomen toward the right flank in the area of abdominal tympany to fluid dullness viii. marking the spot on the patient's abdomen where your percussion note changed from abdominal tympany to fluid dullness a. normal findings: . level of tympany and dullness remain relatiely constant b. deviations from normal findings: . level of dullness shifts upward toward the umbilicus of the abdomen

i.

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