Chapter 19: Abdomen

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Welcome back to another deep dive.

We are the Last Minute Lecture team and today we are putting on our white coats,

metaphorically speaking of course, and tackling what might be one of the most complex, chaotic, and frankly intimidating regions of the human body to examine.

The big one.

It really is.

We are diving head first into Chapter 19 of Bates Guide to Physical Examination.

We are talking about the abdomen.

It is good to be here and you are, you're right to use the word intimidating.

I think a lot of students feel that.

In clinical medicine, the abdomen is often called a black box.

The black box, I like that.

Yeah, because when you look at a chest, you can sort of see the mechanics, right?

You see the ribs expanding, you might feel the heart beating.

It makes a kind of structural sense from the outside.

Right.

But the abdomen, it's soft, it's pliable, and inside there is this incredibly dense packing of solid organs, hollow tubes, fluids,

vasculature, all interacting in ways that are immediately obvious from the surface.

It's a mystery.

Exactly.

It feels less like a machine and more like a, I don't know, biological soup sometimes.

Yeah.

But our mission today is to turn that black box into a transparent one.

We're going to guide you, whether you're a college student, a nursing student, or just stepping into your clinical rotations,

through this material in the exact order of the chapter.

That's key.

We're not skipping around.

No skipping.

We're going to translate the technical skills and the clinical reasoning into plain language.

And we have a lot of ground to cover to really do this justice.

We're going to start with anatomy and physiology to really build a rigid mental map.

You just cannot find pathology if you don't know the territory.

Then we'll move into the health history, which for abdominal complaints is often more diagnostic than the exam itself.

After that, we'll walk through the physical examination step by step, cover the special techniques for things like appendicitis or ascites, talk about how to document your findings with precision, and then wrap up with health promotion.

It sounds like a marathon, but we are going to pace it so it sticks.

You know, I want to start with the tone, the text that's right at the beginning.

I feel like there's this tension in chapter between wanting to just jump in and press on a belly to find the problem, and the need to be incredibly, incredibly careful.

That is the core tension of the abdominal exam.

Absolutely.

The text emphasizes that while we want to demystify the abdomen, we have to be systematic.

If you just start poking around randomly, you'll miss critical clues.

But even more importantly, the abdomen is sensitive.

If your technique is rough or rushed, the patient's muscles will tense up, what we call guarding, and that abdominal wall becomes a shield.

Once that happens, your exam is essentially over.

You can't feel anything.

So you've lost your window.

You've lost it.

So the theme today is really systematic gentleness.

You need a structure in your head before you ever lay a hand on the patient.

Okay, let's unpack this structure.

Section one is anatomy and physiology.

Before we can find a problem, we need to know where things are supposed to be.

Can you orient us?

What are the boundaries we are working with here?

Okay, so think of the abdomen as a large container or cavity.

Superiorly, or at the top, it's bordered by the diaphragm.

That's the big muscle that separates it from the chest.

The breathing muscle.

The breathing muscle, exactly.

Inferiorly, at the bottom, you have the pelvic brim.

That's the bony ring formed by the iliac crests and the symphysis pubis.

Posteriorly, in the back, you have the rigid column of the lumbar vertebrae and those thick paravertebral muscles.

Then up front and on the sides, you have that flexible wall of muscles, the rectus abdominis, the internal and external obliques, and the transversus abdominis.

The six -pack muscles.

Those are the ones.

They aren't just there for aesthetics or core strength.

They are the primary protection for all these organs since there are no ribs covering the front of the belly.

That's a really good point.

They're like a muscular rib cage.

Precisely.

And because they are muscles, they react to stimuli.

That becomes crucial later when we talk about distinguishing voluntary guarding from involuntary rigidity.

We are essentially trying to feel through a muscular wall that can fight back.

Because that container is so full of stuff, we need a grid system to communicate where a problem is.

The book talks about quadrants.

This seems like the standard language, the lingua franca of the abdomen.

It is.

This is how you'll talk to your colleagues every single day.

Imagine two lines crossing right at the umbilicus, the belly button, that gives you four quadrants.

Right upper, left upper, right lower, and left lower.

Simple enough.

But I also saw a nine -region system in the book.

Is that something we need to know, or is it more of an academic thing?

It's good to be familiar with it.

It's a bit more specific, and you'll see it in anatomical texts or maybe older notes.

But more importantly, you'll hear the terms from it all the time.

Terms like epigastric, which is the upper middle area right below the rib cage, or umbilical, which is right in the center.

And hypogastric, or suprapubic, is down low near the bladder.

Clinicians use those terms constantly to localize pain, even if they mostly stick to the four quadrants for describing, say, a mass.

Okay, let's play the mental map game.

This is crucial for you, the listener, to visualize.

If I'm a student and I'm about to palpate the right upper quadrant, or RUQ, what am I actually feeling for?

What's living in that neighborhood?

The superstar of the RUQ is the liver.

It is a massive solid organ that just fills that upper right corner.

It's soft and actually quite difficult to feel in a healthy person because it's tucked up under the rib cage.

The lower margin might just be palpable if you do it right.

So it's kind of hiding.

It's hiding.

And tucked right underneath the liver, deep inside, is the gallbladder.

Now, generally cannot feel a normal gallbladder.

If you can feel it, it's usually distended or inflamed.

Got it.

What else is in there?

You also have the duodenum, the first part of the small intestine looping through there, along with the head of the pancreas and the lower pole of the right kidney.

That's a crowded neighborhood.

And the kidney, why the right one specifically?

Why is that one more likely to be felt?

It's a great question.

It's because the liver is so big, it actually pushes the right kidney down a bit lower than the left one.

So occasionally you might be able to feel the very bottom of the right kidney in a there person.

The left one is just too high up.

Okay, that makes sense.

Let's move over to the other side.

The left upper quadrant, the LUQ.

The LUQ is interesting because the rib cage is very protective there.

You have the spleen, which sits lateral to and behind the stomach.

It's tucked way up high against the diaphragm, protected by the ninth, tenth, and eleventh ribs.

So again, another hidden organ.

Very hidden.

In a healthy person, you generally cannot feel the spleen.

It's soft and it's protected.

You also have the stomach itself and the body and tail of the pancreas running across the back of the abdomen.

So if I'm feeling the spleen, that's usually a sign that something is wrong, that it's enlarged and peeking out from under the ribs.

Precisely.

The text notes that a palpable spleen tip is found in only a small percentage of normal adults.

It's a very small number, something like 5%.

If you can feel it easily, it usually implies splenomegaly or enlargement.

And you have to remember, the spleen is a lymphoid organ.

It swells with infection like mono or with hematologic disorders.

Got it.

Okay, let's move downstairs.

Left lower quadrant,

LUQ.

That's mostly plumbing.

You've got the descending colon coming down the left side, which then turns into the S -shaped sigmoid colon as it dives toward the midline.

And the book says you can sometimes feel that.

Yes.

The text mentions that the sigmoid colon is often palpable, especially if there is stool present.

It feels kind of like a firm, narrow tube that you can roll under your fingers.

In biological females, you'd also find the left ovary and fallopian tube in this quadrant.

And finally, the right lower quadrant.

This is the one everyone worries about in the emergency room.

Correct.

Because of the appendix.

The RLQ houses the cecum, which is the pouch -like start of the intestine.

Attached to the base of the cecum is the appendix.

You also have the ascending colon starting its journey up and the terminal alium where the small intestine ends.

And in healthy people, you can't feel the appendix at all.

You shouldn't be able to feel it.

It's too small and soft.

If you can feel a mass there, it's usually inflammation or worse, an abscess that's formed around a ruptured appendix.

And right down the middle, what are the midline structures?

Midline structures include the bladder, which is only palpable if it's distended with urine, otherwise it sits behind the pubic bone, the uterus in women, and the abdominal aorta.

That aorta is crucial.

Why is that?

You can often see visible pulsations in the epigastrium, especially in thinner patients.

It runs right down the posterior wall, and we need to assess it, especially in older adults.

Now, you mentioned the kidneys earlier, but the text makes a specific point about their location being retroperitoneal.

What does that mean for the exam?

Why is that word important?

It means they lie behind the peritoneum, which is the membrane lining the entire abdominal cavity.

They're way in the back, kind of sandwiched between all the abdominal contents and the big back muscles.

So you can't really get to them from the front.

It's very difficult.

And because of that, we often assess them from the back.

We look for something called the costovertibral angle, or CVA.

That's the angle formed by the bottom of the 12th rib and the lumbar vertebrae.

That is the key site to check for kidney tenderness, like you'd see in a kidney infection.

Before we leave anatomy, we have to talk about the bladder.

The text goes into some surprisingly deep physiology here about how we actually urinate.

It seems like more detail than just the bladder holds fluid.

It does, and it's really important for understanding incontinence, which we'll discuss in the history section.

The bladder is a hollow reservoir made of smooth muscle called the detrusor muscle.

The detrusor.

Yep.

When it expands with urine, it triggers parasympathetic nerves in the bladder wall.

These nerves send a signal up to the spinal cord, which sends a signal back, causing that detrusor muscle to contract.

At the same time, the internal sphincter, which is autonomic, we don't control it, relaxes.

But we don't just pee whenever that loop happens.

We have control, hopefully.

Right.

That's the voluntary part.

The external sphincter is made of striated muscle, which is under our voluntary control.

Plus, higher brain centers in the cortex can inhibit those contractions until the bladder holds about 400 to 500 milliliters.

So it's a conversation between your bladder and your brain.

It's a complex interplay between the autonomic nervous system wanting to empty the tank and our conscious brain saying, not yet, we're in a meeting.

When that coordination fails, that's when you get the different types of incontinence.

Okay, that's our map.

We know the quadrants.

We know the layers.

We know the hidden retroperitoneal spaces.

Now that we have the layout, let's move to section two, health history.

This is where the detective work really begins.

The text suggests that the interview should align with the anatomy we just discussed.

It's a great strategy.

If a patient points to a spot, you should immediately be visualizing the organs underneath.

But the clinician's job here is also to clarify what the patient actually means.

Patients use these umbrella terms.

Oh, totally, like indigestion.

That could mean literally anything.

Exactly.

Indigestion is a non -medical term.

It could mean heartburn.

It could mean they feel gassy.

It could mean nausea.

It could be mild pain or heartburn.

Is that actual reflux or is it cardiac angina?

They can feel very similar or spitting up blood.

Are they vomiting it up from the stomach, which is hematomasis, or are they coughing it up from the lungs, which is hemoptysis?

You have to ask these clarifying questions to nail down the acuity, the quality, and the progression of the symptom.

And speaking of quality, the text breaks down abdominal pain into three very specific categories.

This seems like a cornerstone concept for diagnosis.

If you can understand these three types,

you're well on your way.

Let's break them down.

First up, visceral pain.

Visceral pain comes from the organs themselves, the viscera.

It's triggered when hollow organs like the intestine or the biliary tree contract too forcefully or are distended, or when the capsule of a solid organ like the liver gets stretched.

And the key characteristic is that it's hard to locate, right?

That's the main thing.

The brain has a hard time pinpointing it.

The innervation from these organs is bilateral, and it's sparse compared to the innervation of the skin.

So visceral pain is usually felt midline.

Midline, regardless of where the organ is.

Generally, yes, based on embryologic origin.

So pain from the stomach, duodenum, or pancreas is felt in the epigastrium.

Pain from the appendix, small bowel, or early colon is felt around the belly button periambilical.

Pain from the bladder or the rectum is felt low down in the hypogastrium.

And the quality of the pain, what do patients say it feels like?

It's often described as gnawing, cramping, burning, or aching.

It can be severe, but it's vague in location.

Patients will often rub their open hand over their belly, rather than pointing with a single finger.

So if someone has early appendicitis, it doesn't actually start in the right lower quadrant?

Not usually.

That's a classic pearl.

It often starts as a vague periambilical, visceral, pain, dull pain around the belly button because of the distension of the inflamed appendix.

At that early stage, it's purely a visceral signal.

Okay, so that's visceral, vague and midline.

Then we have somatic or parietal pain.

This sounds more intense.

It is much more intense.

This happens when the inflammation spreads from the organ to the parietal peritoneum.

That's the thin, highly sensitive membrane that lines the abdominal wall itself.

So it's touching the wallpaper of the abdomen.

Perfect analogy.

And that wallpaper has somatic innervation just like your skin.

It has precise localized nerve endings.

So the body knows exactly where this hurts.

Exactly.

This is a steady, aching, and severe pain.

And unlike visceral pain, it is precise.

It's located right over the involved structure.

When that appendicitis inflammation finally touches the abdominal wall in the RLQ, the pain migrates there.

And the patient can point to it with one finger.

And the patient's behavior changes too, right?

This is such a great visual for a student to look for.

Drastically.

With visceral pain like from a kidney stone or a bowel obstruction, a patient might be restless.

They're writhing around, pacing, they can't get comfortable.

But with somatic pain, with peritonitis movement hurts, coughing hurts, even the ambulance hitting a bump on the road hurts.

Wow.

These patients prefer to lie perfectly still, usually with their knees bent to relax the abdominal muscles.

They're guarding against any motion.

So visceral is vague, midline, and makes you restless.

Somatic is sharp, localized, and makes you freeze.

That leaves the third category, referred pain.

This is where the body plays tricks on us.

Referred pain is felt at a distant site that happens to be innervated by the same spinal level as the problem organ.

The brain gets the signal and basically misinterprets the location.

Like the classic heart attack causing left arm pain.

Exactly the same mechanism.

In the abdomen, a classic example is biliary pain, like a gallbladder attack.

The gallbladder is in the RUQ, but the pain is often felt in the right shoulder or at the tip of the right scapula.

That's so strange.

It is, but it's consistent.

Or pancreatic pain radiating straight through the back.

If you only look at the shoulder, you'll miss the gallbladder issue entirely.

You have to know these common referral patterns.

Let's move into section three, upper abdominal symptoms.

We're getting into specific complaints now.

The text separates acute pain from chronic discomfort.

How do we approach acute upper abdominal pain?

For acute upper abdominal pain, the history is your absolute best tool.

You need the timing.

Did it start suddenly or gradually?

Was it like a light switch or did it creep up?

And the location.

Epigastric pain might signal GERD, pancreatitis, or even a perforated ulcer.

RUQ pain points you toward the liver or the biliary tree?

The book gives some really specific examples.

It does.

It says that doubling over with cramping colic pain is classic for a renal stone.

Sudden knife -like epigastric pain that radiates to the back is highly suggestive of pancreatitis.

That kind of specific description is gold.

Then there's chronic discomfort and dyspepsia.

I feel like I see commercials for this all the time.

What is the actual clinical definition of dyspepsia?

Dyspepsia is defined as chronic or recurrent pain or burning that's centered in the epigastrium.

It's often associated with other symptoms like postprandial fullness, feeling uncomfortably full after a normal -sized meal, or early satiety, which is feeling full very quickly.

But just feeling bloated isn't dyspepsia?

Technically, no.

According to the definitions in the text, bloating, nausea, or belching alone doesn't meet the criteria for dyspepsia.

And interestingly, the text mentions functional dyspepsia, which is when a patient has these symptoms for at least three months but has no structural abnormality found on endoscopy.

So it's a diagnosis of exclusion.

It's a diagnosis of exclusion.

We've looked for the camera.

We didn't find an ulcer or a tumor, but the symptoms are real.

We have to talk about GERD, gastroesophageal reflux disease.

It seems incredibly common.

It is.

The diagnostic criteria are actually quite specific.

Heartburn and effortless regurgitation happening more than once a week.

It's caused by things that make the lower esophageal sphincter incompetent, like reduced salivary flow, obesity, or a hiatal hernia.

The acid just splashes back up where it doesn't belong.

What I found fascinating in the text is the discussion of atypical symptoms.

You might not think stomach when you hear them.

Right.

And you, as a student, have to have these on your radar.

Chest pain is a big one.

It can mimic a heart attack and needs to be worked up.

But also coughing, wheezing, and hoarseness.

Hoarseness.

How does that happen?

The acid refluxes all the way up and irritates the vocal cords.

These symptoms can be caused by the acid irritating the upper airway or even microaspiration of acid into the lungs.

It's often mistaken for asthma.

The book makes a great point.

If an adult presents with new onset asthma, you should always consider GERD as a possible cause.

Now, when do we worry?

What are the alarm symptoms or red flags that mean this isn't just simple heartburn?

These are the signs that warrant an urgent endoscopy to rule out something serious like cancer or severe damage, like Barrett's esophagus, which is a precancerous change we're talking about.

Dysphagia, which is difficulty swallowing.

Okay.

Odinophagia, which is painful swallowing.

Recurrent vomiting.

Evidence of GI bleeding, like vomiting blood or having black stools.

Unexplained weight loss.

Anemia or a palpable mass.

It's a jaundice, right?

Yellow skin.

Yes.

Specifically, painless jaundice.

If a patient stains yellow but doesn't have any pain, that is a massive red flag for pancreatic or duodenal cancer obstructing the bile duct.

If you see any of these alarm symptoms, you cannot just treat with antacids.

You need to investigate.

Okay.

Moving down to section four.

Lower abdominal pain.

We touched on the appendix earlier, but let's really cement the classic pattern.

For acute lower pain, if it's in the right lower quadrant, and especially if the patient tells you it started around their belly button and then moved to the RLQ, and it's accompanied by nausea, vomiting, and loss of appetite,

your suspicion for appendicitis should be very, very high.

In women, there's a different list of possibilities.

And a broader differential, yes.

In biological females, we also have to consider pelvic inflammatory disease, or PID, a ruptured ovarian follicle, which can cause sudden sharp pain or an ectopic pregnancy.

And an ectopic pregnancy is a can't miss diagnosis.

It is a life -threatening emergency.

Any woman of childbearing age with lower abdominal pain needs a pregnancy test, period.

What about the left lower quadrant, the LLQ?

If you have fever, loss of appetite, and localized LLQ pain, you should suspect diverticulitis.

That's an inflammation of these little pouches called diverticula that can form in the colon wall.

It's often called left -sided appendicitis because the presentation can be so similar, just on the opposite side.

What about kidney stones?

Those are notoriously painful.

They cause a severe cramping pain that often radiates from the flank down to the groin.

And remember, the behavior kidney stone patients are restless, they're moving around trying to get comfortable.

The pain is described as colicky, meaning it comes in waves as the ureter spasms trying to pass the stone.

The text also lists obstruction and peritonitis.

How do we spot those from the history?

Obstruction presents with diffuse abdominal pain, distension, the belly looks and feels bloated, and something called obstipation.

It means they can't pass gas or stool.

That's a key question.

When was the last time you passed gas?

If the answer is no and they are vomiting, you have to worry about an obstruction.

Peritonitis is that severe diffuse pain with rigidity we mentioned earlier.

It's a surgical emergency.

Okay, let's talk about chronic lower pain, specifically irritable bowel syndrome, or IBS.

It seems like a diagnosis that takes a long time to reach.

It is a diagnosis of exclusion.

The official Roanvafee criteria require intermittent pain for at least 12 weeks out of the prior 12 months.

The key is that the pain is often relieved by defecation and is associated with a change in the frequency or the form of the stool -like going from constipation to diarrhea.

It's functional, meaning the machinery looks normal, but it's acting chaotic.

The associated GI symptoms are also a big part of the history.

Nausea, vomiting, anorexia.

We need to distinguish between terms because patients use them interchangeably, right?

Precision matters here.

Wretching is that spasm without expulsion, the dry heaves.

Vomiting is the actual expulsion of gastric contents.

And regurgitation is raising contents without the nausea or wretching.

It just kind of flows back up, which you see in GRD.

And when there's blood involved, the color tells a story.

This is like forensic pathology in real time.

Absolutely.

Hematomyces is bloody vomit.

If it looks like coffee grounds, it means the blood has been sitting in stomach acid and is partially digested.

That suggests a slower or a stopped bleed from the stomach, like from an ulcer.

Bright red blood suggests an active ongoing bleed that hasn't been digested yet, like from esophageal varices.

Same with stool, right?

Black versus red.

Exactly.

Malena is black, tarry, sticky stool.

It has a distinct, really foul odor.

That usually indicates an upper GI bleed from the esophagus, stomach, or duodenum.

The blood has traveled through the whole gut and been digested by bacteria.

And red blood.

That's hematechesia, red or maroon stool.

That usually means a lower GI bleed from the colon or rectum.

However, and this is an important exception, a massive upper bleed can also cause hematechesia if the blood moves through the gut too fast to be digested.

One term that stood out to me in the reading was early satiety,

feeling full too soon.

Why is that a concern?

It can indicate that something is taking up space in the stomach, like a tumor, or that the stomach isn't emptying properly.

That's a condition called gastroparesis, often seen in diabetes, or it could be a gastric outlet obstruction.

It's a subtle but really important symptom to ask about.

Let's talk about dysphagia difficulty swallowing.

The patient can actually help you locate the problem just by pointing, can't they?

Yes, this is a great clinical tip from the book.

If they point below the sternoclavicular notch, it suggests it's an esophageal dysphagia, not something in the throat.

And then you need to ask a critical branching question.

Is it for solids only or for both solids and liquids?

What's the difference?

Why does that matter so much?

It matters a lot.

If it's for solids only, it's likely a structural issue, a mechanical blockage.

Something like a stricture, a Schatzky ring, or a tumor is making the pipe narrower.

The liquid can get through the small hole, but the piece of bread or steak cannot.

And if it's both?

If it's for solids and liquids right from the start, it's more likely a motility disorder, like achalasia, where the muscles of the esophagus aren't working right to push anything down.

It's a plumbing problem versus a wiring problem.

Moving on to Section 5, jaundice and urinary symptoms.

Jaundice is that yellowing of the skin and eyes.

What's actually happening chemically to cause that?

It's an increase in bilirubin in the blood, specifically when the level gets above 3mgdl.

Normally, the liver processes bilirubin, which comes from broken down red blood cells,

and excretes it in bile.

Jaundice happens when that process breaks down.

And there are different ways it can break down.

Right.

It can be intrahepatic, meaning the liver cells themselves are damaged like in hepatitis or cirrhosis.

Or it can be extrahepatic, meaning the plumbing is blocked after the liver.

The bile ducts are obstructed, maybe by a gallstone or tumor in the pancreas.

And this changes the color of waste products in a very specific telltale way.

It does.

It's a classic sign.

If bilirubin is blocked from getting into the intestine, the stool loses its brown color.

It becomes gray or light colored.

We call that a colic stool.

A colic.

And if that conjugated bilirubin backs up into the blood, the kidneys filter out, turning the urine a very dark tea or cola color.

So tea -colored urine and gray stool.

That points you directly to an obstructive cause.

Exactly.

And if the patient also complains of itching pruritus, that also points to cholestatic or obstructive jaundice because bile salts are depositing in the skin.

Let's shift to the urinary tract.

Men and women often present with different symptoms here.

They do.

Men often have obstructive symptoms because of the prostate.

As the prostate enlarges with age, in BPH, it chokes the urethra.

So men will complain of hesitancy, which is trouble starting the stream, straining to urinate, dribbling at the end, or just a weak stream.

And for women?

For women, a key distinction is internal versus external burning.

Internal burning during urination suggests urethritis or a bladder infection, a UTI.

External burning as the urine passes over the labia suggests vulvoveginitis, an inflammation of the external genitalia.

And incontinence.

It's not just one thing.

There are different types.

The book outlines three main types you have to know.

First is stress incontinence.

This is leaking urine when you cough, sneeze, laugh, or lift something heavy, anything that increases intra -abdominal pressure.

It's a mechanical failure of the sphincter.

Okay.

Second is urge incontinence.

This is when you have a sudden, intense, uncontrolled urge to go.

That's the detrusor muscle contracting when it shouldn't.

Patients say they can't make it to the bathroom in time.

And the third.

And third is overflow incontinence.

This is when the bladder is over -descended and just leaks because it's too full.

It's like a damn overflowing.

This is often due to an obstruction like that prostate issue in men or a neurologic disorder where the bladder can't feel that it's full.

And hematuria blood in the urine.

Gross hematuria is visible to the naked eye.

Microscopic is only found on a urine dipstick.

It's really important to differentiate true hematuria from menstrual blood in women or even reddish urine from certain medications or foods like beets.

But if it's real.

But if it's true hematuria, it always needs a workup to rule out serious things like bladder or kidney cancer or kidney stones.

Okay.

We have taken a very thorough history.

We have a differential diagnosis brewing in our heads.

Now we enter the room to do the exam.

Section six.

Physical examination.

Where do we even start?

Preparation is key.

You cannot examine a tense abdomen.

The first step is to have the patient empty their bladder.

It's better for their comfort.

And a full bladder can feel like a mass and pushes all the other organs out of the way messing up your exam.

Okay.

Bladder empty.

Then what?

They should be lying supine, a pillow under their head, and crucially a pillow under their knees.

Why the knees?

That seems specific.

Flexing the knees relaxes the rectus abdominis muscles.

If their legs are flat on the table, those muscles are stretched and tight, making it much harder to feel anything deep.

Arms should be at their sides, not over their head, because that also stretches the abdominal wall.

And the most important rule.

Ask them where it hurts before you start and examine that area last.

If you start by pressing on the painful spot, they'll tense up everywhere and you won't get any more useful information.

We start with inspection.

We don't touch yet.

Just look.

What are we looking for?

You want to check your position first.

View the abdomen tangentially from the side at eye level.

This helps you see the contour and any subtle pulsations.

We look at the skin for scars from past surgeries, which could mean adhesions.

We look for striae or stretch marks.

Pink -purple striae can be a sign of Cushing syndrome.

Old silver striae are normal.

And veins.

Yes.

We look for dilated veins.

A pattern of veins radiating from the umbilicus called caput medusa is a classic sign of severe cirrhosis and portal hypertension.

Then we check the contour.

Is it flat, rounded, protuberant like it's sticking out?

Or is it scaphoid, which means concave or sunken?

We check for any bulges that could be hernias or any asymmetry.

We check the umbilicus itself.

Is it inflamed or herniated?

And pulsations.

Right.

You might see a normal aortic pulsation in the epigastrium of a thin person.

But if it's markedly increased or looks like a wide expanding mass, you have to worry about an abdominal aortic aneurysm or AAA.

We also look for peristalsis visible wave -like movements across the abdomen.

In a very thin person, it might be normal.

In someone with pain and distension, it could be a sign of intestinal obstruction.

Section 7 is Oscultation.

Listening.

Why do we do this before we touch?

This is a different sequence from the lung or heart exam.

This is unique to the abdomen, and it's a critical point.

Touching, palpating, or percussing can alter the bowel sounds.

You might stimulate them and make them seem hyperactive when they weren't, or you might stop them.

So we listen first to get the true baseline.

And what are we listening for?

We use the diaphragm of the stethoscope, and mostly we're just confirming that bowel sounds exist.

Normal is a range of clicks and gurgles, somewhere between 5 to 34 per minute.

You usually only need to listen in one spot, typically the RLQ, to confirm their presence.

What about Borborygmy?

Borborygmy is just that loud stomach growling we all know.

That's hyperparastalsis.

But more importantly, we are listening for vascular sounds, for brutes.

Brutes are those whooshing sounds.

Exactly.

A whooshing sound caused by turbulent blood flow through a narrowed artery.

We listen over the aorta, the renal arteries, which are just to the left and right of the midline in the upper quadrants, and the iliac and femoral arteries.

A brute in the epigastrium, or upper quadrants, could indicate renal artery stenosis, which is a treatable cause of high blood pressure.

Percussion is tapping.

It tells us about the density of what's underneath.

Gas versus fluid or solid.

A gas -filled structure like the stomach sounds like timpani.

A hollow drum -like sound.

Solid organs like the liver or fluid sound dull.

So what can that tell you?

Well, if a belly is protuberant and it's tympanitic all over, it's likely filled with gas, maybe from an obstruction.

If the flanks are dull when they're lying down, it might be a sites -free fluid in the abdomen.

Then comes palpation.

We start light.

Light palpation is just a gentle dipping motion, with one hand keeping the fingers flat together.

We are feeling for areas of tenderness and for muscular resistance.

This is our first chance to distinguish voluntary guarding from involuntary rigidity.

How do we tell the difference?

This seems like the feel part of the exam that's hard to learn from a book.

It is, but there are tricks.

Voluntary guarding is when the patient is ticklish, anxious, or cold.

It often decreases if you help the patient relax.

Ask them to breathe through their mouth.

Engage them in conversation.

You can feel the muscle soften under your hand when they exhale.

And involuntary rigidity.

Involuntary rigidity.

That board -like stiffness persists no matter what.

It's a reflex contraction of the peritoneum.

That suggests peritonitis and is a major red flag.

Then we go deep with two hands.

Deep palpation is refining the organs and any abnormal masses.

You use two hands, one on top of the other.

The top hand provides the pressure.

The bottom hand stays relaxed and does the feeling.

This lets the bottom hand stay more sensitive.

We are trying to delineate the liver edge, the kidneys, and any masses.

We also check for peritonitis here specifically with a couple of maneuvers.

Yes.

We can ask the patient to cough.

If coughing causes sharp localized pain, that's a positive sign of peritoneal irritation.

Or we check for rebound tenderness.

You press down deep and slow, then you withdraw your hand quickly.

If the pain is worse on the withdrawal, that's positive rebound tenderness.

It means the peritoneum snapped back into place and it hurt.

Section 9 focuses on examining specific organs.

Let's talk about the liver.

It seems tricky to assess.

It is.

We estimate its size first with percussion.

We measure the vertical span in the right midclavicular line, the RMCL.

You percuss up from the RLQ, going from timpani over the bowel until you hear dullness.

That's the lower edge.

Mark it.

Then you percuss down from the nipple line, going from the resonant length sound until you hear dullness.

That's the upper edge.

Mark it.

And you measure the distance between those two marks.

What's normal?

Normal is about 6 to 12 centimeters in the midclavicular line.

But there's a big caveat.

If the patient has COPD, their lungs are hyperinflated.

This pushes the diaphragm down, which also pushes the liver down.

The span might be normal, but the liver will feel low.

You have to be careful not to mistake displacement for enlargement or hepatomegaly.

Then we palpate it.

Yes.

Your left hand goes behind the patient at the 11th and 12th ribs to lift the whole rib cage up toward your other hand.

Your right hand goes on the abdomen, lateral to the rectus muscle, pointing toward the head.

You press in and up while the patient takes a deep breath.

You're trying to feel the liver edge as it descends and slides under your fingertips.

And there's a hooking technique for certain patients.

Yes.

This is really helpful for obese patients where it's hard to feel deep.

You stand at the patient's chest facing their feet.

You hook the fingers of both your hands under the right costal margin.

Ask them to take a deep breath.

You're trying to catch the edge as it comes down.

What does a normal liver edge feel like?

The book describes it as soft, sharp, and smooth.

If it feels hard, blunt, or irregular, that's suspicious for liver disease, like cirrhosis or even cancer.

Now, the spleen.

You said earlier it's hard to feel.

How do we even try?

The spleen, when it enlarges, expands interiorly, downward, and medially.

It replaces the tympani of the stomach with dullness, so we can use percussion to look for that.

We percuss in what's called trob space.

That's the left lower anterior chest wall from the sixth rib down to the costal margin.

It should be tympanitic.

If it's dull, that suggests splenomegaly.

There's also a specific percussion sign, right?

Yes, the splenic percussion sign, or castell sign.

You find the lowest inner space in the left anterior axillary line.

You percuss it.

It should be tympanitic.

Then you have the patient take a full deep breath and hold it, and you percuss again.

And normally, it stays tympanitic.

Yes, the lung just fills that space.

But if the spleen is enlarged, it will slide down into that space during inhalation, and the sound will shift from tympani to dullness.

That's a positive sign.

And palpation.

It's similar to the liver.

You reach over the patient with your left hand to support their rib cage.

Your right hand presses in below the costal margin.

We often have the patient roll onto their right side, which lets gravity bring the spleen forward and down, making it easier to feel.

But remember what we said.

A palpable spleen makes splenomegaly about eight times more likely.

Okay, the kidneys.

Generally not palpable because they're retroperitoneal.

You can try to capture the kidney between your two hands, one on the back, one on the front, while the patient takes a deep breath.

Slight just feel the lower pole of the right kidney in a very thin person.

The main test, though, is checking for CVA tenderness with fist percussion on the back.

Pain plus fever plus dysuria usually equals pylonephritis.

And the aorta.

This feels like a high -stakes part of the exam.

It is.

In adults over 50, we need to assess the width.

You press firmly and deep in the epigastrium, and use one hand on each side of the aorta to feel the edges of the pulsation.

You're estimating the width.

Normal is less than three centimeters.

If it's wider than that, it suggests in AAA an abdominal aortic aneurysm.

And the risk factors.

The big ones are smoking, male gender, and age over 65.

If you find an aorta that's over four or five centimeters, the rupture risk climbs significantly, and that's a surgical emergency.

Section 10 covers special techniques.

These are the maneuvers for specific diagnoses we suspect.

Let's start with the sites.

That's fluid in the abdomen.

A protuberant belly with bulging flanks suggests a sites.

To confirm, we look for shifting dullness.

You percuss the borders of tympani, which is the gas floating on top, and dullness, which is the fluid settling on the sides, while the patient is lying supine.

Then you have the patient roll onto one side and wait a moment.

And then you percuss again.

You percuss again.

In a sites, gravity pulls the fluid down.

The dullness will shift to the dependent side, and the top side, which was dull before, now becomes tympanitic because the bowel has floated up.

If the dullness doesn't shift, it's not free fluid.

What about appendicitis?

We have a whole toolkit of signs for this.

We do.

First, simple point tenderness at McBurney's point.

That's a spot about two inches from the hip bone, the aces on a line to the umbilicus.

Then there's Robson sign.

You press deeply and evenly in the left lower quadrant.

If that causes pain over in the right lower quadrant, it's positive.

It's a form of referred rebound tenderness.

Then the muscle signs.

So as an obturator.

The psoas sign tests for irritation of the psoas muscle.

You have the patient lie on their left side and you extend their right hip back.

Or you can have them lie supine and raise their right thigh against your hand's resistance.

If the inflamed appendix is resting against that muscle, which it often is if it's retrosugal, this will cause pain.

And the obturator.

The obturator sign.

You flex the patient's right thigh and then internally rotate the leg at the hip.

This stretches the internal obturator muscle.

Pain suggests a pelvic appendix is irritating that muscle.

The book notes this sign has low sensitivity, but if it's positive, it's fairly specific.

For acute cholecystitis, a gallbladder attack, we have Murphy sign.

Yes, you hook your thumb or your fingers under the right costal margin where the liver edge is.

Then you ask the patient to take a deep breath.

If the inflamed gallbladder comes down during inspiration and hits your thumb, they will experience a sharp increase in tenderness and suddenly stop their breath.

That inspiratory arrest is a positive Murphy sign.

But you have to have a control.

Exactly.

It's only valid if they don't have the same response when you press on the left side.

We also check for ventral hernias.

These are often hard to see when the patient is just lying flat, so you ask them to lift their head and shoulders off the table as if they're doing a mini crunch.

This tightens the abdominal muscles.

A hernia, which is a defect in the wall, will bulge out.

If it's an intra -abdominal mass, the muscle contraction will usually obscure it by pushing it down and away from your hand.

Section 11 is about documentation.

We've done all this work.

Now we have to write it down clearly.

And precision is everything.

Don't just write abdomen normal.

That doesn't tell anyone anything.

A good note would be abdomen is protuberant with active bowel sounds.

It is soft and non tender.

No palpable masses or hepatosplenomegaly.

Liver span is seven centimeters in the right midclavicular line.

Edge is smooth and palpable, one centimeter below the costal margin.

Spleen, not palpable.

No CVA tenderness.

It paints a clear picture.

And you can contrast that with an abnormal note.

Abdomen is rigid and board -like.

Bowel sounds are absent.

There is diffuse tenderness with rebound and guarding.

That note tells the next person that this is a surgical emergency.

Finally, section 12, health promotion.

We aren't just examining.

We are preventing.

The text highlights viral hepatitis.

We need to know our ABCs.

Hepatitis A is from fecal oral transmission contaminated food or water.

It's usually self -limiting.

There is a vaccine.

Wash your hands.

Hepatitis B.

Hepatitis B is transmitted by blood, semen, and other body fluids.

It can become chronic.

There is a very effective vaccine, which is now standard for infants in the U .S.

And hepatitis C.

Hepatitis C is transmitted primarily by blood, most commonly through injection drug use or from blood transfusions before 1992.

It is the most common chronic blood -borne pathogen in the U .S.

There is no vaccine.

And there's a specific screening recommendation for hep C regarding age, isn't there?

Yes.

For the baby boomer generation adults born between 1945 and 1965, they have a higher prevalence, often from exposures decades ago, before we knew about the virus.

Screening this group is crucial because we now have highly effective curative treatments.

And the last topic, colorectal cancer.

It's the third most common cancer.

And it is very preventable.

Most colon cancers start as benign polyps.

If we do screening, we can find the polyp and remove it before it ever has a chance to become cancer.

What are the screening options for an average risk person?

For ages 50 to 75, though some guidelines are now starting at age 45, there are a few options.

Stool -based tests, like the FIT test or high -sensitivity guayac test, can be done annually.

Colonoscopy is every 10 years, and that's the gold standard because it can both visualize and remove polyps at the same time.

Sigmoidodoscopy is another option every five years.

An important note from the text about the DRE.

Yes, the digital rectal exam is not a colorectal cancer screening test.

It's an important part of the exam for other reasons, but it only reaches the very bottom few centimeters of the rectum.

It can't screen the other five feet of colon.

Okay, we have unpacked the black box.

We've gone from anatomy to history, the exam, special tests, and prevention.

If there is one thing for you to take away from all this, it's that the abdomen is dynamic.

Findings change with the patient's position, with their respiration, and with time.

A systematic approach is the only thing that prevents you from getting lost in there.

A warm thank you from Last Minute Lecture Team for sticking with us through this very deep dive.

Keep practicing those skills.

The hands learn what the mind understands.

It just takes time and repetition.

See you next time.