THE ABDOMEN SELECTED TOPICS R MICHAEL RODRIGUEZ M

THE ABDOMEN – SELECTED TOPICS R. MICHAEL RODRIGUEZ, M. D. ASSOCIATE PROFESSOR OF MEDICINE VANDERBILT UNIVERSITY SCHOOL OF MEDICINE

THE GALLBLADDER

MALIGNANCY COURVOISIER’S SIGN – A PALPABLE NONTENDER GALL BLADDER IN A PATIENT WITH JAUNDICE SUGGESTING EXTRAHEPATIC OBSTRUCTUON OF THE BILIARY SYSTEM SECONDARY TO MALIGNANCY (ORIGINAL DESCRIPTION). CHOLECYSTITIS MURPHY’S SIGN – WITH THE EXAMINER’S FINGERS POSITIONED ALONG THE INFERIOR BORDER OF THE LIVER IN THE RIGHT COSTAL ARCH THE PATIENT IS ALLOWED TO INSPIRE. DURING INSPIRATION THE INFLAMED GALLBLADDER TOUCHES THE EXAMINERS FINGERS RESULTING IN THE SUDDEN CESSATION OF INSPIRATION. BOAS’ SIGN – HYPERESTHESIA AND REFERRED PAIN TO THE RIGHT COSTOPHRENIC ANGLE IN PATIENT’S WITH ACUTE CHOLECYSTITIS. JAMA 1968; 204: 165 J EMER MED 1986; 4: 57 -63

PERITONITIS

PERITONITIS – THE EXAM • GUARDING • REBOUND TENDERNESS • COUGH TEST • CARNETT’S SIGN – ABDOMINAL WALL TENDERNESS TEST

GUARDING – VOLUNTARY CONTRACTION OF THE ABDOMINAL WALL MUSCULATURE. RIGIDITY – INVOLUNTARY CONTOL OF THE ABDOMINAL WALL MUSCULATURE. REBOUND TENDERNESS (BLUMBERG’S SIGN) – THE CLINICIAN MAINTAINS HAND PRESSURE OVER AN AREA OF TENDERNESS. THE CLINICIAN THEN RELEASES THE HAND PRESSURE SUDDENLY. PAIN DENOTES A POSITIVE TEST. MANY OF US DO NOT RECOMMEND THIS EXAM DUE TO THE DISCOMFORT TO THE PATIENT WHO ALREADY HAS LOCALIZED GUARDING. COUGH TEST – IF A PATIENT HAS PERITONITIS, ANY MOVEMENT OF THE ABDOMEN WILL ELICIT PAIN. THEREFORE A COUGH IN A PATIENT WITH PERITONITIS WILL PRECIPITATE PAIN (POSITIVE TEST). ABDOMINAL WALL TENDERNESS TEST (CARNETT’S SIGN) – HELPS TO DISTINGUISH BETWEEN LESIONS OF THE ABDOMINAL WALL WHICH CAUSE PAIN AND PERITONITIS. THE EXAMINER IDENTIFIES THE AREA OF TENDERNESS AND APPLIES MODERATE PRESSURE. THE PATIENT IS ASKED TO LIFT THEIR HEAD AND SHOULDERS. IF THE PAIN IS INCREASED, THE TEST IS POSITIVE (PATIENT HAS A LESION OF THE ABDOMINAL WALL NOT PERITONITIS). PATIENTS WITH PERITONITIS SHOULD HAVE DECREASED PAIN DUE TO THE TENSE ABDOMINAL WALL. HAMILTON BAILEY’S DEMONSTRATIONS OF PHYSICAL SIGNS IN CLINICAL SURGERY, 1986, WRIGHT THE EARLY DIAGNOSIS OF THE ACUTE ABDOMEN, LONDON, 1972, OXFORD UNIVERSITY PRESS BR MED J 1994; 308: 1336

OBTURATOR AND PSOAS SIGN

PSOAS SIGN PRINCIPLE - STRETCH OF PELVIC MUSCULATURE (ILIOPSOAS MUSCLE) WILL ELICIT PAIN. ROLL THE PATIENT ON THEIR LEFT SIDE AND HYPEREXTEND THE RIGHT HIP. PAIN WITH EXTENSION IS A POSITIVE SIGN COPE’S EARLY DIAGNOSIS OF THE ACUTE ABDOMEN, 19 TH ED. OXFORD UNIVERSITY PRESS, 1996

OBTURATOR SIGN PRINCIPLE – SAME AS PSOAS SIGN. THE EXAMINER FLEXES THE PATIENT’S RIGHT HIP AND INTERNALLY ROTATES THE RIGHT HIP. PAIN WITH INTERNAL ROTATION IS A POSITIVE SIGN. COPE’S EARLY DIAGNOSIS OF THE ACUTE ABDOMEN, 19 TH ED. OXFORD UNIVERSITY PRESS, 1996

APPENDICITIS

APPENDICITIS – THE EXAM • • • ROVSING’S SIGN PSOAS SIGN OBTURATOR SIGN RECTAL TENDERNESS MC BURNEY’S POINT TENDERNESS

ROVSING’S SIGN – ALSO KNOW AS INDIRECT TENDERNESS. THE SIGN IS POSITIVE WHEN PRESSURE APPLIED TO THE LEFT LOWER QUADRANT RESULTS IN RIGHT LOWER QUADRANT PAIN. PSOAS SIGN – SEE PREVIOUS SLIDES. OBTURATOR SIGN – SEE PREVIOUS SLIDES. RECTAL TENDERNESS – PATIENTS WITH APPENDICITIS INVOLVIN/G THE PELVIS MAY HAVE RECTAL TENDERNESS ON EXAMINATION. MC BURNEY’S POINT TENDERNESS – A POINT 1½ -2 INCHES FROM THE ANTERIOR SUPERIOR SPINOUS PROCESS OF THE ILEUM ON A STRAIGHT LINE DRAWN FROM THAT PROCESS TO THE UMBILICUS. IN 1889 CHARLES MCBURNEY STATED THAT ALL PATIENTS WITH APPENDICITIS HAD MAXIMAL PAIN AT THIS POINT. J EMERG MED 1986; 4: 57 -63 HAMILTON BAILEY’S DEMONSTRATIONS OF PHYSICAL SIGNS IN CLINICAL SURGERY, BRISTOL, 1986, WRIGHT

ABDOMINAL AORTIC ANEURYSM

ABDOMINAL AORTIC ANEURYSM THE EXAM METHOD THE PATIENT’S ABDOMEN SHOULD BE RELAXED WITH THE KNEES FLEXED. THE EXAMINER FEELS CEPHALAD OF THE UMBILICUS FOR THE AORTIC PULSATION. PLACE BOTH HANDS ON THE ABDOMEN WITH THE INDEX FINGER ON EITHER SIDE OF THE PULSATING AORTA. ESTIMATE THE WIDTH ( NL <2. 5 CM IN WIDTH). JAMA 1999; 281: 77 -81 BATES 8 TH ED, 2003