March 31, 2014

(Doing) every possible examination

maneuver would be as silly as
ordering every possible laboratory test
for fear of missing something.

Jeff Wiese, Clinical Clerkship, 2006

 ,,PE
(Complete Physical Examination)

(which one)?
 ,,PE
(Complete Physical Examination)

(which one)?
(how many)?
 Physical Examination?
 Physical Examination,
Why?

For Diagnosis () of a disease

 Physical Examination,
Why?

For Diagnosis () of a disease

For Therapy () of a disease
 Physical Examination,
Why?

For Diagnosis () of a disease

For Therapy () of a disease

For Disease Screening ()

 Physical Examination,
?

Three basic premises

A Physical Examination is Only a TEST.

(, take history PE.)
 Physical Examination,
?

Three basic premises

A Physical Examination is Only a TEST.

Choice of a test Varies over Time.

(,, PE .
.)
 Physical Examination,
?

Three basic premises

A Physical Examination is Only a TEST.
Choice of a test Varies over Time.

Choose the Best test Available to you.

(, Test?)
Diagnostic Power of a Test
Disease No Disease Total

Test True False a+c

Positive positive positive
a c
Test False True b+d
Negative negative negative
b d
Total a+b c+d a+b+c+d
Diagnostic Power of a Test
Sensitivity
= True positives/All patients with disease (a/a+b)

Specificity
= True negatives/All patients without disease (d/c+d)

* summarized as Positive Likelihood Ratio (LR=Sensitivity/1-Specificity)

 , Test,
(making a Diagnosis), not the other way around.
 , Test, (making a Diagnosis),
not the other way around.

, , Test

Does a Positive Test accurately predict a Disease?

Diagnostic Accuracy of a Test
Disease No Disease Total

Test True False a+c

Positive positive positive
a c
Test False negative True negative b+d
Negative b d

Total a+b c+d a+b+c+d

 Positive Predictive Value (PPV)
= True positives/All patients with positive
test (a/a+c)
Diagnostic Accuracy of a Test
Positive Predictive Value (PPV)
= True positives/All patients with positive test (a/a+c)

, Textbook Test
PPV. Why??
Diagnostic Accuracy of a Test

PPV of a Poor Test-

Sensitivity 50%
Specificity 50%
A Disease No B Disease No
10/100 Disease 90/100 Disease
90/100 10/100
Test 5 45 Test 45 5
Positive Positive

Test 5 45 Test 45 5
Negative Negative

Disease Prevalence = 10% Disease Prevalence = 90%

A Disease No B Disease No
10/100 Disease 90/100 Disease
90/100 10/100
Test 5 45 Test 45 5
Positive Positive

Test 5 45 Test 45 5
Negative Negative

Disease Prevalence = 10%

Sensitivity = 50%
Specificity = 50%
PPV = 10% (5/5+45)
A Disease No B Disease No
10/100 Disease 90/100 Disease
90/100 10/100
Test 5 45 Test 45 5
Positive Positive

Test 5 45 Test 45 5
Negative Negative

Disease Prevalence = 90%

Sensitivity = 50%
Specificity = 50%
PPV = 90% (45/45+5)
A Disease No B Disease No
10/100 Disease 90/100 Disease
90/100 10/100
Test 5 45 Test 45 5
Positive Positive

Test 5 45 Test 45 5
Negative Negative

Dis. Prevalence = 10% Dis. Prevalence = 90%

Sensitivity = 50% Sensitivity = 50%
Specificity = 50% Specificity = 50%

PPV = 10% (5/5+45) PPV = 90% (45/45+5)

Diagnostic Accuracy of a Test

PPV of an Excellent Test, test X

Sensitivity 90%
Specificity 90%
A Disease No B Disease No
10/100 Disease 90/100 Disease
90/100 10/100
Test 9 9 Test 81 1
Positive Positive

Test 1 81 Test 9 9
Negative Negative

Disease Prevalence = 10%

Sensitivity = 90%
Specificity = 90%
PPV = 50% (9/9+9)
A Disease No B Disease No
10/100 Disease 90/100 Disease
90/100 10/100
Test 9 9 Test 81 1
Positive Positive

Test 1 81 Test 9 9
Negative Negative

Disease Prevalence = 90%

Sensitivity = 90%
Specificity = 90%
PPV = 99% (81/81+1)
A Disease No B Disease No
10/100 Disease 90/100 Disease
90/100 10/100
Test 9 9 Test 81 1
Positive Positive

Test 1 81 Test 9 9
Negative Negative

Dis. Prevalence = 10% Dis. Prevalence = 90%

Sensitivity = 90% Sensitivity = 90%
Specificity = 90% Specificity = 90%
PPV = 50% (9/9+9) PPV = 99% (81/81+1)
A Disease No B Disease No
10/100 Disease 90/100 Disease
90/100 10/100
Test 9 9 Test 81 1
Positive Positive

Test 1 81 Test 9 9
Negative Negative

Disease Prevalence = 10% Disease Prevalence = 90%

Sensitivity = 90% Sensitivity = 90%
Specificity = 90% Specificity = 90%
PPV = 50% (9/9+9) PPV = 99% (81/81+1)
A Disease No B Disease No
10/100 Disease 90/100 Disease
90/100 10/100
Test 5 45 Test 45 5
Positive Positive

Test 5 45 Test 45 5
Negative Negative

Disease Prevalence = 10% Disease Prevalence = 90%

Sensitivity = 50% Sensitivity = 50%
Specificity = 50% Specificity = 50%
PPV = 10% (5/5+45) PPV = 90% (45/45+5)
Diagnostic Accuracy of a Test
:
Two Determinants of PPV (Positive Predictive Value)

1. Sensitivity and Specificity (or Positive Likelihood

Ratio,LR): pre-determined
Diagnostic Accuracy of a Test
:
Two Determinants of PPV (Positive Predictive Value)

1. Sensitivity and Specificity (or Positive Likelihood

Ratio,LR): pre-determined

2. Disease Prevalance (or Pre-test Probability), of a

disease: not known before patient interview
 Physical Examination,
?

Three basic premises

A Physical Examination is Only a TEST.
Choice of a test Varies over Time.

Choose the Best test Available to you.

(, Test PPV. History
Taking Pre-test Probability.)
 A Good History Taking
tells you how likely your patient has a
disease.
 Recap
Physical Examination?

For Diagnosis of a disease

For Therapy of a disease

For Disease screening

?
Common Clinical Settings for
Physical Examination on Abdomen
For Diagnosis of Abdominal Pain (diagnosis and
therapy)
For Evaluation of the Severity of Abdominal Pain and
Liver Disease (therapy)
As Routine Screening examination in Adult
(screening)
Within practical limits, there
is no such thing as a
routine (screening) physical examination.
Nevertheless, every physician adopts or acquires certain habits of
examination. He develops a routine or basic examination that he
follows with most patients, (His) procedures not only differ
from those of his colleagues but are
not exactly
repetitive with each of his own patients.

DeGowin & DeGowins Bedside diagnostic examination, 5th ed., p46


Abdominal Physical Examination List?
Two-Tier Approach of a Routine
Physical Examination on Abdomen
A. Tier I Exam ()
- PE (for Disease Screening)
- PE
- Test of High Sensitivity and Pre-test probability
Two-Tier Approach of
Physical Examination on Abdomen
B. Tier II Exam ()
- Tier I exam positive , for Screening
- Done for Diagnosis of a disease
- Done for Evaluation of Disease Severity (therapy)
- Test of High Specificity
Principles of Abdominal Examination

Inspection and palpation are more important in

abdominal examination, while auscultation is the
most useful method applied to the chest .

Abdominal examination follows different order:

1. Inspection
2. Auscultation
3. Palpation
4. Percussion
Tier I Abdominal Examination
on Screening
 Tier I Abdominal Examination
on Screening
Step 1: Inspection
Abdominal Surface Anatomy
 Tier I Abdominal Examination
on Screening
Step 1: Inspection
- Abdominal contour
- Skin discoloration
- Pulsation
- Focal splinting
- Scarring
- Dilated Veins
- Hernia
Sister Mary Josephs Nodule
 Sister Mary Josephs Nodule
Description: A hard nodule located at the umbilicus.

Pathophysiology: A metastatic tumor, either via blood

vessels or lymphatics, or contiguous spread, from the
peritoneum to the umbilicus. More often described in
adenocarcinoma of an abdominal origin.

LR: Probably low sensitivity. It tells you poor prognosis

if present in your patients with above cancers.
Grey Turners Sign
 Grey Turners Sign
Description: Ecchymosis of the flanks.

Pathophysiology: Blood moves from the

retroperitoneum to the abdominal wall musculature
and subcutaneous tissues, or bleeding in the above
tissues.

LR: Low sensitivity (14/770) and low specificity in

patients with acute pancreatitis.
Cullens Sign
 Cullens Sign
Description: Peri-umbilical ecchymosis.

Pathophysiology: Blood tracks from the

retroperitoneum, via the gastro-hepatic, falciform and
finally the round ligament, to the abdominal wall
around the umbilicus, or bleeding around the
umbilicus.

LR: Low sensitivity (9/770) and low specificity in

patients with acute pancreatitis.
 Choosing a best test
Both Grey Turners and Cullens signs are observed in
patients with acute pancreatitis. But both are poor tests
with low sensitivity and low specificity.

In patients with no clinical history or acute pancreatitis,

these tests are even worse because of low pre-test
probability and low sensitivity/specificity.

So, we dont do it as a routine test;

we dont use it to make the diagnosis of acute
pancreatitis.
 Tier I Abdominal Examination
on Screening
Step 2: Auscultation
- Bowel sound (?)
- Arterial bruit
(Do it when pre-test probability is high.)
 Tier I Abdominal Examination
on Screening
Step 3: Palpation to exclude abdominal pain
- Shallow palpation to detect areas of tenderness and
guarding
- Deep palpation to detect mass lesion (Tier II)
 Tier I Abdominal Examination
on Screening
Step 4: Percussion
- General percussion if abdomen is distended
- Assess liver size
Palpation of Liver
 LR for
Enlarged Liver
Tier II Abdominal Examination
 Tier II Abdominal Examination
For diagnosing the cause of abdominal pain
For confirming the diagnosis of liver disease and
assessing disease severity
For confirming the diagnosis of splenomegaly
When Tier I abdominal exam is positive and dictates a
diagnostic exam
 Tier II Abdominal Examination
All Tier II abdominal examination has a pre-
determined pre-test probability through
patients history or screening Tier I examination.

So, we choose examinations of high sensitivity

and specificity (or combined as LR).
 Tier II Abdominal Examination
on Abdominal Pain
Step 1: Inspection
- Any skin and subcutaneous lesions
- Abdominal shape and contour
- Patients apprehension
Step 2: Auscultation
- Presence or absence of bowel sound
- Arterial bruit
Step 3: Palpation
- Local tenderness and rebound pain (tenderness)
Step 4: Percussion and other maneuver
 Tier II Abdominal Examination
on Abdominal Pain
Ask your patient to locate the area of maximum
tenderness with one finger first.
Let your patient relax his/her abdominal muscle.
The painful area is examined last.
Local tenderness indicates local muscle guarding.
Dont be cruel to your patient. Testing rebound
tenderness is unnecessary when involuntary rigidity is
present.
 Pathophysiology of
Tenderness and Muscle Guarding
 LR for
Abdominal Pain/Peritonitis
 LR for
Abdominal Pain/Appendicitis
Location of McBurneys point
 Psoas sign for
retro-cecal appendicitis
Tier II Abdominal Examination
on Cirrhosis
 Tier II Abdominal Examination
on Cirrhosis
Step 1: Inspection
- Abdominal contour and shape
- Superficial vein engorgement
Step 2: Auscultation
- Venous hum from para-umbililcal shunting
Step 3: Palpation
Step 4: Percussion
- Presence of ascites
- Assess liver and spleen sizes
 Tier II Abdominal Examination
on Cirrhosis
Signs of portal hypertension from increased
mesenteric flow
- Superficial vein engorgement
- Ascites
- Splenomegaly
Superficial Vein Engorgement
 Superficial Vein Engorgement
Description: Dilated veins of abdominal wall, radiating
from the umbilicus, in portal hypertension, or laterally
located when IVC is occluded.

Pathophysiology: Portal hypertension causes back

flow from the portal vein to the para-umbilical veins,
or IVC occlusion causes collaterals flow through
superficial veins of the abdominal wall.

Test value: Diagnosis and assessment of the severity of

portal hypertension.
 Detecting Ascites by
Flank bulging and Fluid wave
 Pathophysiology of
Shifting Dullness in Ascites
 Shifting dullness in Ascites
Description: Shifting of tympany-dullness interphase
line upon assuming lateral decubitus position. But it
takes at least one minute to level the proteinaceous
ascitic fluid.

Pathophysiology: Gas-filled loops of bowel always

float on the top of ascitic fluid.

LR: Detection threshold of 500ml. Obese abdomen

may give a positive test of shifting dullness.
 LR for
Presence of Ascites
 Tier II Abdominal Examination
on Cirrhosis
Signs of portal hypertension from increased mesenteric flow
- Superficial vein engorgement
- Ascites
- Splenomegaly
Sign of hyper-estrogenemia
- Spider angioma or naevi
- Palmar erythema
- Gynecomastia
- Testicle atrophy
Spider Angioma or Naevi
Palmar erythema
 LR for
Presence of Cirrhosis
 Recap

Ten take-home messages

 1. physical examination.

2. physical
examination.
 3. Physical exam of abdomen should always be
performed in order (), inspection,
auscultation, palpation and percussion.
Inspection and palpation are the most useful.
 5. Physical examination . Do it after
a good history taking to increase the pre-test
probability of diagnosing a disease.

6. test of higher sensitivity and specificity

(or likelihood ratio).
 7. pathophysiology of each sign you detect.
 8. physical exam:
a routine screening exam?
a diagnostic exam for abdominal pain or cirrhosis?
an exam for assessing disease severity of an
inflamed abdominal organ or of cirrhosis?.
 9. Physical examination has a lot of inter-observer
disagreement. .
 10. Physical examination ?
Questions ?
References
Clinical clerkship: the answer book. J Wiese.
Lippincott Williams & Wilkins. 2006.
DeGowin & DeGowins bedside diagnostic
examination. RL DeGowin. Macmillan 5th ed. 1987.
Evidence based physical diagnosis. S McGee. Saunders,
2nd ed. 2007.
Mechanisms of clinical signs. M Dennis, WT Bowen &
L Cho. Churchill Livingstone. 2012
Sapiras Arts and sciences of bedside diagnosis. JM
Orient. Lippincott Williams & Wilkins. 2000.