The Thoracic Exam
Utilizing any good physical examination textbook, such as The Physical Examination by Barbara Bates, MD, review the techniques of a thoracic exam. Of importance when performing this examination on the presentation of Acute Abdomen is to ascultate for cardiac arrthymias, murmurs, mechanical heart valves, signs of pneumonia or trauma. Many missed diagnosis of the patient presenting with the acute abdomen are pulmonary such as pneumonia, vascular such as abdominal aortic aneurysm or cardiac, such as an acute MI. Also make sure that there is at least a nasal O2 at a minimum of two liters and to keep the saturation above 97%.
The Abdominal Exam
The abdominal examination consists of the three aspects of look, listen and feel. With the patient in a supine position with slight head elevation and perhaps a pillow under their knees begin the exam by observation. Is there any distention? There exists a large difference between the patient who presents with abdominal obesity and the patient who has an obstruction and a drum like abdomen filled with air or gas. If the patient is thin, the examiner will be able to observe peristalsis and, if so, to chart its presence. Is there any obvious discoloration such as Cullen’s sign or Gray Turner’s sign? If you are unsure of these conditions look for the definition and etiology in your textbook. Are there any scars on the abdomen? If so, there is the beginning of the thought process that this patient may have intra-abdominal adhesions and have a bowel obstruction. Are there visible signs of herniation such as umbilical hernia, inguinal hernias, incisional hernias or femoral hernias? Ascultate for the presence of bowel sounds. Are the bowel sounds hypoactive, hyperactive, is there borborygini or is the abdomen silent? All of these are signs of a surgical abdomen from bowel obstruction, and remember, a silent abdomen is like silent respiration in an asthmatic: it is potentially deadly. Percuss the abdomen to discern if the distension is due to air of fluid, and feel all four quadrants, eliciting signs of tenderness. In deference to the patient, we no longer do rebound testing with a deep pressure and quick release as this can be ascertained by shaking or bumping the stretcher or asking about the ride to the hospital and observing the position of the patient. Discover the point of maximum tenderness, CVA or flank tenderness and peritoneal signs. Is there warmth over the abdomen and is the peristalsis felt when gently palpating the four quadrants? The abdomen is all about signs, and all clinicians should be familiar with Mc Burney’s Point (its location) as well as how to perform a Psoas sign and what this means, an Obturator sign and its implications, Rovsing’s sign in relation to diverticulitis and Murphy’s sign. If these physicians thought it important enough to put their names on it, then it must be of importance to the examiner.
Pelvic, Rectal, GU and Extremities
There is never a time when the word deferred or omitted should be used for this part of the exam. In an academic situation where the student is presenting an H&P, the student should be failed on their examination if these words are used as they generally relate to slothfulness, embarrassment on behalf of the student or the patient and these are essential to discovering the etiology of the pain. The patient should be appropriately draped and an assistant should be present and a full pelvic exam should be done on females and a testicular exam should be performed on males. The pelvic exam may reveal evidence of infection such as malodorous discharge, may reveal vaginal bleeding, cervical motion tenderness (Chandeliers’ sign), adnexal masses or foreign body. A clinician should never be surprised at what they may find or should not telegraph this to the patient. There may be an old tampon that had been forgotten because of a procedure the previous week, or there may be foreign bodies such as vegetables, frankfurters, fruit or other types of FB present. Any experienced examiner has seen this in emergency medicine or in women’s health. The male patient will occasionally have a FB in the urethra and will give vivid and unusual stories relating to its presence. The rectal exam in both sexes is to discover bleeding, masses, hemorrhoids, tumors, rectal wall integrity, sphincter control or the lack thereof which may be evidence of a neurological disorder or sexual preference. Occasionally this region may have a foreign body that will require surgical removal and sometimes a colon resection. Suspect the unusual or bizarre and you will never be caught off guard. Examination of the extremities is of importance because of the possibility of aneurysm and a diminished blood flow to the area below the iliac bifurcation. This will need radiological confirmation as well as early Doppler testing.
What is the main reason for a rectal exam?
A. R/O internal hemorrhoids
B. Observe for Sphincter control
C. Palpate for a tumor
D. Check for occult or gross blood
What is the most appropriate lab in a 26 Y/O female?
A. WBC
B. Amylase/Lipase
C. HCG
D. KUB
The Basic Laboratory workup in the patient with an acute abdomen is a urinalysis, amylase/lipase, pregnancy test, LFT’s, EKG, CXR, Flat and upright of the abdomen, KUB and Doppler studies. For more complex cases or presentations, one should consider an Ultrasound, computed tomography, angiography, barium enema, or laparoscopy in child bearing age and on pediatric patients.
The most appropriate complex exam to R/O appendicitis is:
A. CT Scan
B. Ultrasound
C. Barium enema
D. FAST
What are Common Causes of the Acute Abdomen? That will be part of part Vl when we discuss other abdominal problems and how to discover them.
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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