Why a Physical Diagnosis Course

1
Why a Physical Diagnosis Course?

• In one study (Baker et al 1978), attending
  vascular surgeons compared themselves with the
  housestaff.
• Each was allowed to take a history, palpate the
  abdominal aorta, the popliteal, dorsalis pedis,
  and posterior tibial pulses and also to use a
  stethoscope.
• For additional information the patient could be
  exercised until symptomatic and the exam
  repeated.
• In 102 pts, the attendings made a correct
  diagnosis in 96 of pts and were partially
  correct in 4 (compared to angiography).
• Housestaff were correct in 62 pts, partially
  correct in 35, and totally wrong in 3.
• Noninvasive tests (ultrasound, ABI) were better
  than the younger physicians but NOT as accurate
  as the experienced attendings.

2
Introduction to the Abdominal Exam

• Acute abdominal complaints are very common.
• 41 of all patients in an ambulatory practice
  have abdominal pain as one of their presenting
  complaints.
• It is among the top three reasons to present to
  an emergency department.
• Can include benign causes or catastrophic
  illness.
• There can be no question that in acute abdominal
  disease, it is of the utmost importance to
  diagnose early. --Copes Early Diagnosis of the
  Acute Abdomen

3
Introduction to the Abdominal Exam

• The necessity of making a thorough physical
  examination in every acute abdominal case should
  not need much emphasis. The vast array of tests
  available to all of us today will not compensate
  for a poor or incomplete history and physical
  examination.
• A thorough history and physical is what directs
  further testing to define, in a timely fashion,
  the cause of the abdominal symptoms.
• This enhances pretest probability of any further
  testing to make a more accurate diagnosis.
• The abdominal exam is interesting! It
  incorporates knowledge of anatomy, physiology,
  and neurology.

4
Objectives

• By the end of these two didactic sessions,
  participants will be able to
• --describe the components of the complete
  abdominal exam inspection, auscultation,
  percussion, palpation
• --describe specialized maneuvers for detecting
  certain disease states
• --recognize strengths and limitations
  (sensitivity and specificity, likelihood ratios)
  of specialized physical exam maneuvers and
  positive findings

5
Timeline

• Today Discuss techniques of inspection,
  auscultation (45 minutes).
• 15 minute break.
• Discuss percussion, palpation, and specialized
  maneuvers (45 minutes).
• Feb 27th review four disease states
  (cirrhosis, appendicitis, splenomegaly, AAA) and
  discuss specific PE techniques.
• Feb 25th, March 4th PE rounds in the hospital.
  Meet on 6B at 130. Should conclude by 330.

6
Inspection

• Actually begins the minute you walk in the room.
• Many observations can be made while you are
  taking the history position, facial expression,
  movement.
• Patients with a perinephric abscess tend to bend
  towards the side of the lesion.
• The Psoas Sign leg of the involved side is
  flexed at the knee, externally rotated at the
  hip.
• Patients drawn up into fetal position consider
  ulcer, pancreatitis.
• Sitting up leaning forward pancreatitis.
• Restless patients may have renal colic or bowel
  obstruction.
• Peritonitis causes the patient to lie very still.
• Begin the PE with examining the bared abdomen at
  the foot of the bed.

7
Inspection

• Abdominal contours of note
• --Visible waves of peristalsis
• --Pseudocyst producing localized bulge, or
  Cupids Bow of acute pancreatitis
• --Asymmetry due to hepatosplenomegaly
• --Localized distention bladder, terminal
  ileum, large bowel
• --Generalized distention the Five Fs
  Fluid, Fat, Feces, Flatus, Fetus (Dr. Ron
  Soltis)
• --Venous patterns, everted umbilicus,
  eccymoses, striae

8
The humble belly button

• Umbilicus within 1 cm of the midpoint between
  the xiphoid and the symphysis pubis.
• Downward displacement is usually caused by
  ascites.
• Upward displacement is caused by pregnancy,
  bladder distention, or pelvic tumors.
• Eversion is less specific but can be due to
  ascites, increased intraabdominal pressure, obese
  abdomen with lax abdominal muscles, or hernia.

9
Ecchymoses

• Subcutaneous blood from intraperitoneal or (more
  commonly) retroperitoneal hemorrhage may dissect
  to the skin overlying the flanks or abdominal
  wall.
• Cullens sign periumbilicul. Cullen was a
  Baltimore OB who described this finding in a case
  of ruptured ectopic pregnancy.
• Grey Turner Sign G. Grey Turner described flank
  discoloration in a patient with acute hemorrhagic
  pancreatitis.
• ANY cause of intra or retroperitoneal hemorrhage
  may cause these signs (nonspecific), and usually
  these findings are rare and appear late in the
  hospital course (not very sensitive).

10
Venous Patterns

• Prominent venous patterns may be seen in portal
  hypertension, inferior vena cava syndrome, or
  superior vena cava syndrome.
• Normal collaterals drain cephalad if they are
  cephalad to the umbilicus caudad if they are
  caudad to the umbilicus.
• In portal HTN, normal flow is preserved but veins
  enlarge around the umbilicus (caput medusae).
• In IVC syndrome collaterals are more lateral, and
  all drain cephalad.
• In SVC syndrome, they all drain caudally.

11
Other observations

• Many abdominal complaints are related to alcohol
  consumption pancreatitis, gastritis, hepatitis,
  cirrhosis, ascites.
• Early EtOH abuse telangectasias of the nose and
  face, periorbital edema, mild HTN.
• Withdrawal state moist, sweaty skin, fine
  tremor, HTN, tachycardia.
• Cirrhosis jaundice, scleral icterus, spider
  angiomata, palmar erythema, gynecomastia.

12
Moving on to Auscultation

• At the present time, this is a surprisingly
  controversial subject. Some gastroenterologists
  see no point in listening for bowel sounds,
  whereas others with gray beards find it highly
  valuable.
• --Sapiras Art Science of Bedside Diagnosis
• Points of agreement this should be done prior
  to any palpation or percussion usually described
  as present or absent beyond that, generally low
  yield.

13
Auscultation

• High pitched tinkles and rushes are suggestive
  of small bowel obstruction.
• Generally, these occur intermittently during the
  cramping episodes of abdominal pain (every 10-20
  minutes).
• Similar sounds can occur with increased
  peristalsis during diarrhea.
• Complete absence of bowel sounds can be due to
  advanced intestinal obstruction, secondary ileus,
  or can be a normal finding in between periods of
  motility.

14
Auscultation Other stuff

• Bruits a renal artery bruit may be heard just
  above the umbilicus anteriorly or just below the
  CVA posteriorly.
• It is generally high pitched, can radiate over
  anterior abdominal surface and also the flanks.
• Technique can listen with the diaphragm while
  using moderate pressure, or with the bell pressed
  in deeply.
• Systolic bruit alone can also be associated with
  RAS (39-75), AAA (28) but also in a percentage
  of normals (16).
• Requiring a diastolic component makes the test
  less sensitive but more specific for renal artery
  stenosis (esp d/t fibromuscular dysplasia).

15
Auscultation Other stuff

• Venous hum Can be heard in thin normals, more
  pronounced in anemia. Can also due to portal
  HTN hum can be heard above the umbilicus and it
  gets louder during Valsalva.
• Succussion splash due to large amount of air
  and fluid in the stomach during gastric outlet
  obstruction.
• Rubs can be heard over the liver in hepatoma,
  cholangiocarcinoma, and 10 of cases of mets to
  liver. Also can be heard over an inflamed
  gallbladder, splenic infarct, renal infarct.

16
Percussion

• Although percussion can elicit tenderness it is
  usually employed to estimate size of organ
  liver, spleen, bladder.
• Liver beginning at right midclavicular line,
  percuss from resonance to dullness. Determine
  upper and lower borders, measure span between
  them.
• Can enhance accuracy by having patient hold
  their breath and using a softer percussion note.

17
Percussion

• Spleen Percuss over the lowest intercostal
  space in the left anterior axillary line, during
  expiration and deep inspiration. Enlarged but
  nonpalpable spleen will cause dullness during
  inspiration.
• Percussion of the semilunar space of Traube
  (borders two parallel lines 9th rib at the
  axillary line to the costal margin, and 6th rib
  at the costochrondral junction down to the costal
  margin) dullness suggests either pleural
  effusion or splenomegaly.
• Percussion of the bladder begin at pubic
  symphysis in the midline and move cephalad.

18
Palpation

• Performed in an orderly sequence, beginning in
  the RUQ and preceding to the LUQ then LLQ then
  RLQ.
• Patient positioning is key often helpful to
  have the patient flex knees and hips with soles
  of feet on the bed have pt put hands on chest.
• Palpation assesses for localized tenderness,
  specific organ enlargement and consistency, or
  masses.

19
Palpation of specific organs Liver

• The four main purposes of palpation are
• --to evaluate consistency
• --to feel the liver for nodules
• --to find extremely large livers
• --to detect hepatic pulsations
• Stony hard liver tumor
• Hard liver with sharp edge cirrhotic
• Pulsations right heart failure, hemangioma
• Nodule, if palpable, usually indicates tumor
• --nodular cirrhosis rivers on a plain
• --tumors mountains on a plateau

20
Palpation of specific organs Spleen

• With the patient supine, stand at the patients
  right and feel for the spleen with your right
  hand below the costal margin, pressing fingers in
  deeply.
• May be aided by placing the left hand in the
  sub-CVA area, or, over the lateral aspect of the
  costal margin and drawing upward to catch
  spleen.
• Can also ask the patient to place his left fist
  under the left CVA, then perform palpation on the
  patients left, curling fingers of both hands
  under the left costal margin and asking the pt to
  take a deep breath. (Hooking maneuver of
  Middleton)
• Alternatively, place pt in modified right
  lateral decub position and stand behind patient
  examine with right hand anterior and left hand at
  posterior axillary line.

21
Palpation of specific organs Spleen

• Have the patient sit up in a chair lean over
  pts left shoulder from behind, palpate with your
  left hand in the pts left anterior axillary line
  using the right hand medial to the left.
• Place pt in a prone position supporting his
  weight on knees and elbows or knees and chest
  palpate in LUQ for spleen tip.
• Place pillow between knees of supine patient.
  Have him place left fist underneath ribs.
  Examiner stands on patients left and palpates
  with both hands under left costal margin.

22
Palpation of specific organs Spleen

• Place pt in right lateral decub position while
  examiner remains on the right side of the patient
  and palpates with the right hand (Russian method
  of Povzhitov) if left hand is used this is the
  Danish method of Videback.
• Videback also described same maneuver with the
  patient in the left lateral decubitus position.
• Bimanual palpation of the spleen can be
  performed with the patient standing and bent
  slightly forward (right hand reinforcing CVA and
  left hand palpating at left costal margin).
• It has been claimed that splenic palpation may
  be enhanced by have the patient jump up and down
  20 times and performing the standing exam.

23
Palpation in the Presence of Pain

• Alternate the pattern so that the area of pain
  is examined last.
• Assess for local rigidity (guarding) usually
  implies local peritonitis.
• --in the most extreme case, abdominal wall is
  constantly rigid.
• --in the lesser form, muscles tense when the
  examiners fingers touch the skin.
• --in the least form, rigidity ensues when deep
  palpation occurs.
• Is it visceral pain or abdominal wall pain?
  Chin to chest or sit up maneuver will decrease
  pain that is intraperitoneal and increase pain
  that is abdominal wall.

24
Palpation in the Presence of Pain

• Rebound tenderness a general method for
  picking up peritoneal irritation.
• Hand performing deep palpation is abruptly
  withdrawn stretching of the peritoneum then
  brings on pain. (Blumbergs sign, rebound
  tenderness.)
• Referred rebound test possibly useful if you
  suspect the patient is not being completely
  cooperative.
• Other rebound tests Copes method (cross
  palpation), Blumbergs method (pressure in the
  left iliac fossa bringing about any pain),
  Rovsings sign (pressure in the left iliac fossa
  bringing about pain in the RLQ, suggestive of
  appy)

25
Special Maneuvers

• Valsalva a 20 second vigorous Valsalva can
  often localize a specific area of tenderness.
• Obturator test purpose is to move the
  obturator passively, which should not produce
  pain unless a nearby structure is inflamed.
• --with the patient supine flex the thigh and
  rotate it fully inward
• --standing lateral to the leg, pull ankle
  toward you and push knee away
• --test is positive if it produces pain (usually
  central abdomen, hypogastrium)
• --on the left, suggestive of appy if both
  sides, pus or blood in the pelvis

26
Special Maneuvers

• Psoas maneuver detects irritation of the
  psoas muscle from appendicitis, abscess, or
  hematoma. Have the patient roll onto his left
  side hyperextend the right hip assess for pain.
• Murphys sign press deeply into the right
  upper quadrant, have the patient take in a deep
  breath. Positive sign is cessation of
  inspiration as the inflamed GB hits the
  examiners hand.

27
Rectal

• Examine the perianal area for fistulas,
  draining sinuses, ulceration hemorrhoids.
• Anteriorly, in men, palpation of the prostate
  may produce pain in prostatitis.
• In women, anterior mass or pain can indicate
  carcinomatosis or pelvic abscess.
• Laterally to the patients right, can elicit
  tenderness from an inflamed appendix (especially
  retrocecal appy).
• Laterally to the patients left, diverticulitis
  or abscess may produce tenderness.
• Immediately posterior, pain can be elicited
  during inflammation of the sacrococcygeal joint.
• Tumors may be located on any of the above
  areas.
• Stool hard, impacted vs. bloody vs. heme
  positive.

28
Pelvic

• An immensely obese patient who abused alcohol
  in the past was admitted late at night to the
  medical service of a well known county hospital.
  The chief complaint was abdominal pain. The
  intern diagnosed pancreatitis, placed an NG,
  began IV fluids and went to bed
• The next morning the nurse called frantically to
  inform him of the presence of a newborn infant in
  the patients bed.
• Called on cross cover to give a patient a dose
  of oral fluconazole for a presumed yeast
  vaginitis. Patient was complaining of thick
  white discharge and itching.
• A quick speculum exam was performed, revealing
  a retained tampon.

29
Pelvic

• External exam fistuale, condylomata.
• Speculum exam examine the cervix for redness,
  purulent drainage. Send cultures, possibly pap.
• Bimanual exam assess for cervical motion
  tenderness (chandelier signPID), tenderness
  over adnexa (TOA, ectopic, ovarian torsion or
  cyst).
• Assess for mass or fullness (uterine fibroma,
  endometriosis, tumor).

30
Objectives

• By the end of these two didactic sessions,
  participants will be able to
• --describe the components of the complete
  abdominal exam inspection, auscultation,
  percussion, palpation
• --describe specialized maneuvers for detecting
  certain disease states (Cirrhosis, Appendicitis,
  Splenomegaly, AAA)
• --recognize strengths and limitations
  (sensitivity and specificity, likelihood ratios)
  of specialized physical exam maneuvers and
  positive findings

31
In conclusion

• The vomiting of blood of any kind is bad its
  passage as excrement is not a good sign, nor is
  the passage of black stools.
• --Hippocrates, Aphorism 425
• You can observe a lot by watching.
• --Yogi Berra
• We insist on the same regimen, plus the use of
  chicken soup.
• --Barron Larrey (surgeon to Napoleon)