Psoas sign: Pain with extension of right hip or flexion of right hip against resistance.
Atypical Pain: Pelvic Appendix
Rectal and Pelvic Exams:
Rule out pelvic disease in women
Demonstrate tenderness of pelvic appendix (especially if atypical pain pattern)
Obturator sign: Pain with internal rotation of the right hip.
Epigastic, Umbilical, hypogastric (suprapubic)
Hypochondrium, Lumbar (flank), Ingunal (iliac)
Vascular Bruit - CAD will hear bruit
Ascititc fluid seeks the lowest point in the abdomen, producing bulging flanks that are dull to percussion. The umbilicus may protrude. Turn the patient onto one side to detect the shift in position of the fluid level (shifting dullness)
-Metastatic colon cancer
-Chronic liver disease (cirrhosis)
-Abdominal malignancy (carcinomatosis)
-Right sided heart failure
-Thrombosis of hepatic vein or inferior vena cava (Budd-Chiari syndrome)
Bacterial endocarditis, tuberculosis)
-Neoplasm (Lymphoma, acute and chronic leukemia, PCV)
-Malignancy (Metastatic cancer, primary liver cancer, lymphoma, leukemia)
-Fatty liver disease (alcohol, diabetes)
-Right lower quadrant pain on palpation (the single most important sign)
-Low-grade fever (38°C [or 100.4°F])--absence of fever or high fever can occur
-Localized tenderness to percussion
-Flank tenderness in right lower quadrant (retroperitoneal or retrocecal appendix)
-Patient maintains hip flexion with knees drawn up for comfort
Psoas sign - pain on extension of right thigh (retroperitoneal/retrocecal appendix)
Obturator sign - pain on internal rotation of right thigh (pelvic appendix)
Rovsing's sign - pain in right lower quadrant with palpation of left lower quadrant (pain when pressing on oposite side at same point as apendix)
Dunphy's sign - increased pain with coughing
McBurney's Point - half way between ASIS & umbilicus, where you would make incision
Atypical Pain: Retrocecal Appendix
-Pain/ Tenderness Pattern:
-Guarding/ Rebound Tenderness
Cough or percussion tenderness
6-12 cm in right midclavicular line
4-8 cm in midsternal line
-The predominant percussion note over abdomen
-Gaseous distention of viscera
Dullness: Ascites, organomegaly, tumor
-Guarding: Rigidity (muscular spasm) vs. voluntary
Percuss the left lower anterior chest wall to detect splenomegaly in the area termed :
-change in percussion notre from tympany to dullness on inspiration suggests splenic enlargement: Positive splenic percussion sign
-Perforated viscus (e.g., perforated duodenal
ulcer, ruptured appendix, etc.)
-Organomegaly:Liver, spleen, kidneys, bladder
-Masses:Physiologic = pregnant uterus
Inflammatory = Diverticulitis, Crohn’s disease (iliocecal area)
Vascular = Aneurysms
Neoplastic = CA
-Ascites is excess fluid in the space between the tissues lining the abdomen and abdominal organs (the peritoneal cavity).
-Usually an indication of severe liver disease.
-Caused by high pressure in the venous blood vessels of the liver (portal hypertension) and low albumin levels.
-Pain and tenderness:
-May be well localized or referred
-Pain aggravated by movement and cough
-Rebound or percussion tenderness
-Guarding = Abdominal rigidity (“board-like
abdomen”)body's defense mechanism
-Absent or decreased bowel sounds
If blood can’t flow easily through the liver due to scarring (cirrhosis) or inflammation (hepatitis) portal vein pressure increases (hypertension) often causing weak-walled vessels (varices) that can rupture and cause hemorrhaging.
Veins that transport blood from:
-Digestive organs (stomach, SB, Lg. Intestine) and
-Spleen, pancreas and gall-bladder to the liver.
Look for Hernias, Pulsations, Peristaltic Activity
above 3cm atotic
above 5cm = bad
Auscultation first because percussion and palpation may alter the frequency of bowel sounds.
Generalized: Obesity (protuberant),Ascites, Intestinal obstruction (gaseous distention), Peritonitis (ileus)
Upper Abdomen:Hepatomegaly, splenomegaly, pancreatic cyst or tumor, gastric outlet obstruction, aortic aneurysm, hernia
Lower Abdomen:Uterus, ovary, bladder, hernia, intestinal mass
Decreased:(late bowel obstruction, paralytic ileus, peritonitis)
-Bowel sounds are typically absent with peritonitis.
Increased:(gastroenteritis, laxatives, early intestinal obstruction, GI hemorrhage)
-Bowel sounds may be high pitched and occur in frequent waves (“rushes”) with early bowel obstruction.
Anorexia, Indigestion, Early Satiety, Hertburn,Retching, Regurgitation, Vomiting,Hemetemesis, Dysphagia, Odynophagia, Change in Bowel function
- constipation (less than 3/week)
- obstipation(not even passing gas,secondary to obstruction)
- melena (upper GI bleed)/hematochezia
- greasy/oily stools (malabsorption vs
-occurs when hollow organs (intestines or biliary
tree unusually contract, distend or stretch.
-difficult to localize.
-experienced at the midline.
-gnawing, burning, cramping, sweating, pallor,
-Early stages of appendicitis.
-experienced at a more distant site.
-innervated at approximately the same dermatomal level as the disordered structure.
-Often develops as the initial pain intensifies
and appears to radiate.
-radiating pain (acute cholecystitis=R sld,
-originates in the parietal peritoneum.
-caused by inflammation.
-steady aching pain over the involved structure.
- P > V (tenderness/guarding -> rigidity/rebound)
-aggravated by movement/coughing.
-Afferent (inflammation) signals are sent from the specific area and localized to the dermatome superficial to the site.
-Supine (with pillow under head)
-Abdomen exposed (“full exposure from below the xiphoid to the symphysis pubis”)
-Knees flexed and arms at side (to avoid
tightening of abdominal muscles)
-Ensure that patient has an empty bladder
-Start on the right side of the patient
-Wash and warm hands; warm stethoscope
-Any areas of pain ?
sense of retrosternal or epigastric burning with radiation to the neck often associated with possible gastric reflux (r/o coronary artery disease-CAD)
inability to consume a normal size meal
raising gastric contents w/o N/V/Retching
spasmodic movements of chest and diaphragm
vomiting blood (often “coffee-ground” appearance)
-usually peptic ulcer disease
forceful expulsion of gastric contents through mouth
pain on swallowing (burning or squeezing) – candidiasis vs muscular cause
Lower R kidney & ureter
Cecum & appendix
Liver & Gallbladder
Pylorus & Duodenum
Head of pancreas
Hepatic Flexure of colon
R adrenal & upper kidney
Lower L kidney & ureter
Left lobe of liver
Spleen & Stomach
Body of pancreas
Splenic flexure of colon
L adrenal & upper kidney
Important Structues: Decending colon, Sigmoid colon, Uterus, Urinary Bladder, Vermiform Appendix, Cecum, Terminal Ileum,Abdominal Aorta, Psoas Major & Minor
Important strudtures: Liver, Stomach, Spleen, Kindeys
localized post-prandial epigastric discomfort