By Marven Ewen, MD, Medical Director
A patient asked me the other day after I palpated his abdomen, “What is it you guys look for when you do that?”
I explained the rationale of the abdominal exam to him, and thought this might be a good review for EMTs. Before you read any further, try to answer this question: What are you assessing with the abdominal exam?
There are some things that can be discovered by examining the abdomen, but it is important to have a consistent approach to the exam. Firstly, as with exams of most areas of the body, we begin with inspection. How does the abdomen look? Is the skin appearance normal? Are there rashes or bruising? People that inject subcutaneously in the abdominal area, such as diabetics on insulin, or people taking lovenox (blood thinner), often have some superficial bruised areas on the lower abdomen.
In the case of trauma, are there abrasions or bruising from the seat belt or steering wheel? This would raise your suspicion for the likelihood of internal injuries. Also, bruising of the umbilicus (Cullen sign) or flanks (Grey Turner Sign) are late indicators of a retroperitoneal hemorrhage. Are scars present from prior surgery? With the advent of laparoscopic surgical techniques, the scarring can be minimal even in patients with prior major abdominal surgeries. Two or three very small 1 cm scars are a clue to this - typically one of the scars will be at the umbilicus.
While inspecting the abdomen, notice the overall shape. Is it distended? Common reasons for a distended abdomen include pregnancy or bowel obstruction.
After inspection, I like to auscultate the abdomen. I listen for the presence of bowel sounds. Absence of bowel sounds raise my suspicion for a serious bowel problem or trauma. The presence of a bruit could indicate vascular disease. A bruit sounds like a “whooshing” sound that peaks in intensity with each heartbeat.
The next step is palpation. Start with a light touch: lay your hand on each quadrant of the abdomen and gently just flex and release your fingertips. Occasionally patients are so ticklish they can’t stand another person touching their abdomen. Lay your hand over their hand in each quadrant and palpate. Sometimes in uncooperative small children, I have the parent palpate the child’s abdomen under my direction, noting any tenderness. Notice if the patient experiences pain with this. Is the abdomen rigid or soft? Common causes for a rigid abdomen include intra-abdominal hemorrhage and peritonitis. Peritonitis is a serious infection of the peritoneal lining of the abdomen, which typically causes extreme pain on palpation as well. If pain is present with this very light palpation, proceed with caution. If the patient complains of abdominal pain in a specific quadrant before your exam, examine that area last and don’t touch it again.
Next, gently and slowly using one of your hands over your other hand for support, palpate each quadrant, noting tenderness and any palpable masses. Stop pressing if the patient is too tender. Tenderness in the RUQ is common with gallstone pain. Left upper quadrant tenderness sometimes with radiation to the left shoulder is common with spleen injury. Most often there will be RLQ tenderness in appendicitis. LLQ tenderness is common with diverticulitis.
Common masses include stool in colon, abscesses, and tumors. A pulsatile mass in the center of the upper abdomen raises suspicion for an aortic aneurysm in an older patient (don’t palpate this mass again during reassessment). Although, in thin people the pulsation of the normal aorta can be felt easily. In an older patient with back or abdominal pain, check the groin pulses as well. Loss of a groin pulse may indicate a dissection of an AAA (Abdominal Aortic Aneurism).
After you have palpated all quadrants, do it again more lightly but releasing your pressure quickly. Observe for rebound tenderness. If the patient indicates the release of pressure caused pain, ask if it hurt where your hand just was, or did s/he feel it somewhere else in the abdomen. For example, rebound tenderness may radiate to the RLQ in acute appendicitis. Don’t do this more than one time if the patient has rebound tenderness. It will cause unnecessary suffering and the patient will lose trust in you.
Finally, if you are a paramedic or work with paramedics that can give IV medications per protocol, it should be noted that treating the patient’s abdominal pain with a reasonable amount of IV pain medicine will not impair the exam in the ER. Withholding pain medicine to avoid masking exam findings in a patient with severe pain is unnecessary and cruel.