28 pág.


DisciplinaPropedêutica Clínica178 materiais1.753 seguidores
Pré-visualização2 páginas
Abdominal and Lower 
Extremity Exams
Charlie Goldberg, MD
Professor of Medicine, UCSD SOM
Abdominal Exam
\u2022 4 Elements: Observation, Auscultation, 
Percussion, Palpation
\u2022 Pelvic, male genital & male/female rectal
exams all critical parts of Abdomen exam 
Æ covered next year
(please wait for video to load)
Surface Anatomy
Supra-Pubic Area
Epigastric Area
\u2022 Exposure Æ Drape
for success!
\u2022 Good lighting, 
warm room, table 
flat, hands at side, 
head resting on 
\u2022 +/- Feet flat on 
Observation (cont)
\u2022 Make note of : 
\u2013 general shape
\u2013 contours 
\u2013 symmetry
\u2013 color
\u2013 scars
\u2022 ? easiest to make 
observations from 
foot of bed.
\u2022 Examine from R
Examples of Abnormal Findings On 
Obese Ascites (fluid), Yellow Enlarged gall 
Umbilical Hernia (R with Valsalva)
\u2022 Normal intestinal propulsion of 
food (peristalsis) generates 
\u2022 Listen (diaphragm of 
stethoscope) x 15-20 seconds in 
4 quadrants
\u2022 Pay attention to: presence, 
quantity (nl ~ 2-5 seconds), & 
quality of sounds
Auscultation (cont)
\u2022 Clinical utility: 
\u2013 Intestinal Obstruction: 
Increase in frequency early 
(\u201crushes\u2019) Æ declines in 
quantity, increase pitch 
(\u201ctinkles\u201d) Æ stop
\u2013 After being handled (surgery) 
Æ no function or noise 
(ileus) Æ w/normal recovery, 
noise returns
\u2013 Infection of mucosa
(gastroenteritis) Æ increased
\u2022 No findings pathognomonic
\u2022 Auscultation not helpful in 
otherwise normal exam 
\u2022 Clinical context most important
Auscultation (cont)
\u2022 Bruits - sounds of 
turbulent arterial flow 
Æ atherosclerosis
\u2022 Listen over:
\u2013 Renal arteries
(several cm above 
umbilicus, either side 
\u2013 Iliac arteries (below 
\u2022 Same principle as for Lung exam
\u2022 Tapping over solid or liquid filled structureÆ
dull tone; air filledÆtympanitic (resonant)
\u2022 Percussion provides sense of what\u2019s beneath
skin & bones \u2013 e.g: liverÆdull; air filled 
\u2022 Abdomen not designed to facilitate exam for 1st 
yr med students!
\u2013 Important solid structures protected - liver 
& spleen by ribs; pancreas & kidneys deep in 
retro-peritoneum; bladder & uterus in pelvis
\u2013 Central abdomen filled w/intestines: freely 
movingÆ promotes peristalsis, tolerates direct 
Percussion Technique
\u2022 Stand on R side
\u2022 Middle finger of non-
percussing hand firmly 
against abdomen
\u2022 Using floppy wrist
action, hammer middle 
finger of other hand
down, aiming for last joint 
\u2022 Percuss all 4 quadrants
\u2013 nl =s mix of dull and 
Percussion Technique (cont)
\u2022 Liver span (6-12 cm) \u2013
Start in chest, below 
nipple (mid-clavicular 
line) & move down \u2013
tone changes from 
resonant (lung) to dull
(liver) to resonant
\u2022 Spleen \u2013 small, located 
in hollow of ribs \u2013
percussion over last 
intercostal space, 
anterior axillary line 
should normally be 
resonant \u2013 dullness 
suggests splenomegaly
\u2022 Stomach \u2013 tympanitic
(epigastric area)
Percussion \u2013 Shifting Dullness
\u2022 Detect large 
amounts of 
pathological fluid 
\u2022 Intestines will 
float to surface
\u2022 Percussion can 
detect air-fluid 
\u2022 Change in 
position shifts
point of interface
\u2022 Most important 
structures aren\u2019t 
\u2022 Warm your hands
\u2022 Generally right hand
used (left placed on top 
or @ your side)
\u2022 Palpate using pads & 
edges of middle 3 fingers
\u2022 Gentle pressure, no 
sudden movements
\u2022 Think about what \u201clives\u201d
in area you\u2019re examining
Palpation Technique
\u2022 First explore superficial 
aspect each quadrant
(start R lowerÆR 
upperÆL upperÆL lower)
\u2022 Deeper palpation
\u2013 Start R lower, moving up
towards R ribs 
\u2013 Move hands a few cm up 
w/each palpation
\u2013 Push down (posterior) & 
then towards head 
\u2013 As approach ribs, palpate
while patient inspires 
deeply (diaphragm brings 
liver down towards hand)
\u2013 Might feel liver edge in 
normals (usually not)
Palpation Technique (cont)
\u2022 Deeper Palpation (cont)
\u2013 Palpate towards L upper
quadrant from midline & 
below - use L hand to \u201cpull\u201d 
spleen towards you
\u2013 Above umbillicus, L of 
\u2013 Push down (deep) 
w/palpating hand 
Remainder of abdomen
\u2013 Uterus, bladder, other 
(rarely palpable)
\u2022 Evaluate painful areas 
Palpation/Percussion Of 
The Kidneys
\u2022 Kidneys are 
retroperitoneal structures, 
deep & protected by the ribs 
Æ rarely palpable
\u2022 If markedly enlarged, may 
appreciate in lateral aspects 
abdomen (rare)
\u2022 Assess for tenderness via 
posterior approach, tapping
on back at Costo-Vertebral 
Angle \u2013 if kidney infected 
(pyelonephritis), patient will 
have Tenderness (CVAT)
Area of Costo (rib)-
Vetebral Angle(s)
Exposed Deep 
Put Findings TogetherÆ Paint 
The Best Picture
Abdominal exam techniques compliment each 
\u2022 Ascites
\u2013 Observe distention, 
bulging flanks
\u2013 PalpationÆ no 
evidence of mass 
\u2013 PercussionÆ shifting 
\u2022 Enlarged liver
\u2013 Percussion indicates 
extension of liver 
below diaphragm
\u2013 Palpation confirms 
location of lower edge 
(also detects contour, 
Lower Extremity Exam \u2013
General Observation, 
Including Femoral Region
\u2022 Expose both legs, noting: 
asymmetry, muscle atrophy, 
joint (knee, ankle) abnormalities
\u2022 Focus on Femoral Area:
\u2013 Inspect - ? Obvious 
swellingÆ femoral hernia v 
large lymph nodes (rare)
\u2013 Palpate lymph nodes
Note: Ok to skip femoral 
observation today in 
anatomy lab!
Femoral Region (cont)
\u2022 Identify femoral pulse
\u2022 Listen over femoral artery with 
diaphragm stethescope for bruits (if
suggestion vascular disease by hx, 
Femoral Artery Anatomy
\u2022 Observe for evidence 
swelling, discoloration, 
\u2022 Range of motion -
flexion to full extension 
Æ ? pain or limitation
\u2022 ? Warmth on palpation
\u2022 W/knee sl bent, push 
fingers into popliteal
fossaÆassess popliteal 
\u2022 Detailed examination of 
internal structures knee 
(ligaments, meniscus, 
etc) Æ next year!
Feet and Ankles
\u2022 Lower leg & feet @ 
greatest risk 
atherosclerosis and 
neuropathy (in U.S.) \u2013
particularly if Diabetes
\u2022 Observe
\u2013 ? swelling (edema), 
discoloration, ulcers, 
nail deformities
\u2013 Look @ bottom of 
feet, between toes 
(problem areas)
\u2013 Symmetry?
Blue discoloration 
from chronic venous 
Red discoloration 
from acute infection
Nail thickening and 
discoloration from chronic 
fungal infection
Feet and Ankles (cont)
\u2022 Palpation
\u2013 Temperature: Use back of examining hand -
warmÆinflammation; coolÆatherosclerosis 
&/or hypo-perfusion
\u2013 Capillary refill: push on end of toe or nail bed 
& releaseÆ color returns in < 2-3 seconds; 
longerÆ atheroscloerosis &/or hypo-perfusion
Feet and Ankles (cont)
\u2022 Palpation (cont)
\u2013 Edema: Quantify 
(subjective) & 
determine extent (how 
\u2022 trace (minimal), can be 
subtle loss of tendons on 
top of foot, contours 
\u2022 4+ =s \u201ca lot\u201d - pitting 
(divot left in skin after 
pressure applied) 
Edema obscuring tendons, 
edge of malleolous
4+ edema with pitting
Dorsalis Pedis Pulse
\u2022 Palpate Dorsalis Pedis
\u2013 Just lateral to extensor
tendon great toe
\u2013 Use pads of 2-3 fingers
of examining hand
\u2013 Push gently
\u2013 If unsure whether feeing 
your pulse v patient\u2019s, 
measure your carotid or 
their radial w/other hand
\u2013 Graded 0 (not 
detectable) to 2+