Inspect the abdominal wall for asymmetry, distention, displacement of the umbilicus, respiratory motions, ecchymoses, and venous patterns.
Listen, especially for bowel sounds, before palpating. Also check for hums, bruits, and rubs.
Palpate the abdomen in an orderly sequence, reserving any painful areas for last.
Consider the possibility of pregnancy in all women of child-bearing age.
Palpate for tenderness, masses, abnormal pulsations, and enlargement of organs or the aorta.
anterior abdominal wall and cause a discoloration resembling a bruise or a subcutaneous injection site of heparin.
FIGURE 20-1 Lateral abdominal contours. A: Cupid’s bow of pancreatitis. B: Fat. C: Bladder distention.
FIGURE 20-2 A: The everted umbilicus sign of chronic ascites. Drawing of an Igbo female tutelary spirit pit display in the Baltimore Museum of Art. B: A false positive everted belly button seen in an obese patient possessing a lax abdominal wall. There was no evidence of portal hypertension, hypoalbuminemia, liver disease, or ascites by any imaging procedure. Another false positive is shown in Fig. 20-4. (Courtesy of Dr Tim Rice of Missouri.)
FIGURE 20-5 Ward Rounds, lithograph by Robert Riggs. What is your diagnosis? Three that have been offered are pregnancy, ovarian cyst, and ascites. What do you think of each of these? (Appendix 20.1.) What is the patient holding in her left hand? (From Medicine and the Artist [Ars Medica], with permission of the Philadelphia Museum of Art.)
TABLE 20.1 Differential diagnosis of abdominal pain
TABLE 20.2 Some causes of intermittent abdominal pain
If the patient has, for example, pain in the right upper quadrant, which was unconvincing to previous examiners, press slowly and deeply into a place where there is no pain, such as the left upper quadrant.
Then release the pressure suddenly, as if to test for rebound tenderness in the left upper quadrant, and ask, “Does that hurt?”
the right hand. This assumption is traditional in medicine but not very important. If you feel more comfortable beginning on the left and examining with the left hand (or with the right hand for that matter), then perform the examination that way. If you modify the text to accommodate your own preference, knowledge of basic anatomy will permit you to alter the instructions mutatis mutandis.
FIGURE 20-7 The McBurney point is on the dotted line, 1.5 to 2 in. from the anterior superior iliac spine. The area to check for the Murphy sign (see text) is marked by the “X.” (David, by Michelangelo.)
If you wish to hear bowel sounds, you should apply your stethoscope to the abdomen before performing palpation or percussion because these may disturb the peritoneal contents into silent pouting. (However, after percussion, the auscultation should be recorded in the case record in the usual sequence.)
As far as the routine screening physical examination is concerned, auscultation of the bowel sounds is of low yield.
Warm the chest piece of your stethoscope by rubbing it briskly in the palm of your hand.
Lightly rest the chest piece of the stethoscope in each of the four quadrants of the abdomen. Listen for bowel sounds. If no bowel sounds are heard, enter this fact in the case record, along with a note about the length of time that you listened. To hear the tinkles and rushes1 of small bowel obstruction, which occur between periods of silence every 10 to 20 minutes (during episodes of cramping abdominal pain), you must listen for 20 minutes! Major (Delp and Manning, 1975) cleverly makes the suggestion that if there is anything to suggest the presence of a small bowel obstruction, one should begin the auscultation of the abdomen during the interview. Remove one of the stethoscope earpieces from your ear to listen to the patient’s words. When the patient interrupts his story because of abdominal pain, switch your attention to the ear that is connected to the stethoscope.
Feel free to modify this method according to the comments below.
With the patient supine, flex the thigh and rotate it fully inward (Fig. 20-9).
Repeat on the opposite side.
Have the patient roll onto his left side. Hyperextend the right hip (away from the position that the patient would naturally assume with a right psoas sign—see the drawing of St Sebastian, Fig. 5-2) to see whether pain can be elicited.
Repeat on the other side to check for nonappendiceal left psoas lesions.
have been investigated in a comparative fashion is given in Tables 20.4 and 20.5.