THE BLADDER

Distention above symphysis pubis aids examination

Palpation
Normal: smooth and round upon palpation, no tenderness
Percussion
determine dullness, determine how high bladder rises above
symphysis pubis.
(+) Dullness: if distended with 400 to 600 ml urine.

THE AORTA

Deeply palpate the aortas pulsations from the left of midline a few cm above
umbilicus. Estimate its width by deeply pressing on each side of aorta.
Periumbilical mass with expansile pulsations 3 cm in
diameter in abdominal aortic aneurysm. Assess further due to
risk of rupture.
(+)pain signals rupture. High risk of rupture for aneurysms
>4cm.
Aortic width affected by thickness of abdominal wall and AP
diameter of the abdomen.

Assessment of special techniques:

ASSESSING ASCITES
o Ascites: protuberant abdomen with bulging flanks.
Percuss for dullness in dependent areas of abdomen. (outward
percussion from central area of tympany). Map border of
tympany and dulness.
Test for shifting dullness. We have finished mapping areas of
tympany and dullness with patient supine, now map the area
with patieny lying on side.
o What do we expect to find in ascites?Ascitic fluid
usually shifts to dependent side, changing the
margin of dullness.

Test for a fluid wave. Ask patient or an assistant to press edges

of both hands into midline of abdomen. Tap one side and feel for
a wave transmitted to the other side.
o NOTE: A palpable wave suggests but does not
prove ascites but it makes the diagnosis highly
likely.
Ballotte an organ or mass in an ascitic abdomen. Place your
stiffened and straightened fingers on the abdomen, briefly jab
them toward the structure, and try to touch its surface.
 o Your hand, quickly displacing the fluid, stops
abruptly as it touches the solid

ASSESSING POSSIBLE APPENDICITIS

Questions to Ask--------------------------------In classic appendicitis:

Where did the pain begin? ---------------------Near the umbilicus

Where is it now? ------------------------------Right lower quadrant (RLQ)
Ask patient to cough. Where does it hurt?------RLQ at McBurneys point"
Palpate for local tenderness. -------------------RLQ tenderness
Palpate for muscular rigidity. -------------------RLQ rigidity

Perform a rectal examination and, in women, a pelvic examination

o Rovsings sign: Press deeply and evenly in the left lower quadrant.
Then quickly withdraw your fingers.
(+) if pain in the right lower quadrant during left-sided pressure
suggests appendicitis.
o Psoas sign: Place your hand just above the patients right knee. Ask the
patient to raise that thigh against your hand. Or, ask the patient to
turn onto the left side. Then extend the patients right leg at the hip to
stretch the psoas muscle.
(+) if pain from irritation of the psoas muscle suggests an
inflamed appendix.
o Obturator sign: Flex the patients right thigh at the hip, with the knee
bent, and rotate the leg internally at the hip, which stretches the
internal obturator muscle.
(+) if right hypogastric pain, suggesting irritation of the
obturator muscle by an inflamed appendix.

ASSESSING POSSIBLE ACUTE CHOLECYSTITIS

Auscultate, percuss, and palpate the abdomen for tenderness.

Bowel sounds may be active or decreased; tympany may
increase with an ileus: Assess any RUQ tenderness.
Assess for Murphys sign. Hook your thumb under the right costal
margin at edge of rectus muscle, and ask patient to take a deep
breath.
Sharp tenderness and a sudden stop in inspiratory effort
constitute a positive Murphys sign.