PEMERIKSAAN ABDOMEN

KKD
UNPAR

Senin 18 September 2017

SIAS SIAS kiri
 HIPOKONDRIUM

LUMBAL

ILIAKAL

4 KUADRAN 9 REGIO
 XIPHOID
process

AORTA

TRANSVERSE
colon
ILIAC artery

DESCENDING
SIGMOID colon

full BLADDER
COSTOVERTEBRAL
ANGLE
 Tympany

Dullness

GAS TUMOR

tympany

dullness

Ascitic Fluid
LIPOMA

INFANT Incisional Hernia Epigastric Hernia

Bising usus
Right Midclav.line

4-8 cm in midste
line
6-12 cm in rig
midclav.line
right midclav.line

right midclav.line
 SPLEEN
(ORGAN TERLINDU
KOSTA)

(S 1-8 ) (1,2,3,4)
COSTOVERTEBRAL
ANGLE
 Tympany

Dullness

GAS TUMOR

Ascitic Fluid
LIPOMA

INFANT Incisional Hernia Epigastric Hernia

BATAS REDUP
dan
timpani
Pemeriksaan Ascites
Right Midclav.line

4-8 cm in midste
line
6-12 cm in rig
midclav.line
right midclav.line
 SPLEEN
(ORGAN TERLINDU
KOSTA)

(1,2
,3,4
)
(S 1-8 )
(S 1-8 )
(1,2,3,4)
PERHATIKAN
PEMERIKSAAN ABDOMEN

Anamnesis
 HISTORY QUESTIONS
PAIN IN ABDOMEN
CHANGE IN APPETITE
CHEWING AND SWALLOWING
PROBLEMS
HEARTBURN
NAUSEA, VOMITING, REGURITATION
RECTAL BLEEDING
HISTORY QUESTIONS

ELIMINATION
HEMORRHOIDS
VOIDING DIFFICULTY
PREVIOUS SURGERY
WEIGHT GAIN OR LOSS
TYPE OF DIET
MEDICATIONS
 Dysphagia
Signs and symptoms
Reports of difficulty swallowing
Difficulty controlling food or saliva in
mouth
Facial droop
Dementia, frailty, confusion
Inability to sit upright

42
 Gastroesophageal Reflux
Disease
Signs and symptoms
Heartburn
Indigestion
Belching:(also known as burping, ructus, or eructation)
involves the release of gas from the digestive tract (mainly esophagus
and stomach) through the mouth.

Hiccups
Regurgitation of gastric contents
Voice hoarseness

43
 Liver and Biliary Disorders
Signs and symptoms
Older adults often present with vague,
ambiguous symptoms
Fatigue
Weight loss
Anorexia
Malaise

44
PEMERIKSAAN ABDOMEN

Think
Anatomically
 Think Anatomically
When looking,
listening, feeling and
percussing imagine
what organs live in
the area that you are
examining.
Quadrants & Regions of the abdomen

MSP: mid-sagittal plane RLL: right lateral plane

TUP: transumblical plane (L4/5) LLL : left lateral plane
TPP: transpyloric plane (L 1)
TTP: transtubercular plane (L 5)
Regions of the abdomen
Right Upper Quadrant (RUQ)
liver, gallbladder,
duodenum,
right kidney
and hepatic
flexure of colon
Right Lower Quadrant (RLQ)
Cecum,
appendix (in
case of female,
right ovary &
tube)
 Left Lower Quadrant (LLQ)

Sigmoid
colon (in case
of female, left
ovary & tube)
 Left Upper Quadrant (LUQ)
Stomach,
spleen, left
kidney, pancreas
(tail), splenic
flexure of colon
 Epigastric Area
Stomach,
pancreas
(head and
body), aorta
 Landmarks of the abdominal wall,

Costal margin,
umbilicus, iliac crest,
anterior superior iliac
spine, symphysis
pubis, pubic tubercle,
inguinal ligament,
rectus abdominis
muscle, xiphoid
process.
Physical Examination of the
Abdomen
Inspection
Auscultation
Percussion
Palpation
Special Tests
 General Considerations
1. The patient should have an empty bladder.
2. The patient should be lying supine on the exam table and
appropriately draped.
3. The examination room must be quiet to perform adequate
auscultation and percussion.
4. Watch the patient's face for signs of discomfort during the
examination.
5. Use the appropriate terminology to locate your findings
6. Disorders in the chest will often manifest with abdominal symptoms.
It is always wise to examine the chest when evaluating an abdominal
complaint.
7. Consider the inguinal/rectal examination in males. Consider the
pelvic/rectal examination in females.

EXAM SECTIONS
1. Inspection
2. Auscultation
3. Percussion
4. Palpation
 1. INSPECTION

Physicians locate findings in the abdomen in one of

four quadrants or one of nine regions.
The four quadrants are:
right upper (RUQ),
right lower (RLQ),
left upper (LUQ) and
left lower (LLQ).

THE NINE REGIONS

epigastric,
umbilical,
hypogastric/suprapubic,
right hypochondriac,
left hypochondriac,
right lumbar,
left lumbar,
right inguinal and
left inguinal.
 1. INSPECTION

HAIR DISTRIBUTION
UMBILICUS
CONTOUR
o a. FLAT
o b. ROUNDED
o c. SCAPHOID
o d. PROTUBERANT
(DISTENDED)
PERISTALSIS
 LOCATIONS of ABDOMINAL ORGANS

The schematic below is a reminder of what

organs are likely to produce findings in each
region.
For example:
Right hypochondriac (RUQ) : liver and gall
bladder
left hypochondriac (LUQ) : the spleen and
stomach
epigastric : the pancreas, stomach and
common bile duct
umbilical : the small intestine
lumbar : the kidneys
iliac regions : the ovaries
left iliac/LLQ : the sigmoid colon
right iliac or lumbar (RLQ): the cecum and
appendix
suprapubic : the bladder and uterus
SOME COMMON FINDINGS on ABDOMINAL
INSPECTION
Scars : Jaringan parut
Striae (stretch marks) : tanda peregangan ibu hamil
Colors : - Bluish color at the umbilicus is Cullen's sign a sign
of bleeding in the peritoneum.
- Bruises on the flanks are Grey Turner's sign
(retroperitoneal bleeding - e.g. from inflamed
pancreas)
Jaundice : warna kuning pada kulit
Prominent veins : may be due to portal vein
obstruction or inferior vena cava obstruction
 ABDOMINAL DISTENSION
Distension of the lower abdomen only can be
caused by pregnancy, full bladder, ovarian tumor,
or uterine fibroids (common benign growths)
Diffuse abdominal distension can be caused by any
of the 6 Fs:
Fat (obesity)
Fluid (ascites - peritoneal fluid - or obstructed viscera
filled with fluid)
Flatus (air) - e.g. from air swallowing or intestinal
obstruction
Feces (constipation
Fetus (pregnancy)
Fatal cancer.
Appearance of the abdomen

Is Aortic pulsation?
Is it flat or Scaphoid
(Normally)?
Distended?
If enlarged, does this
appear symmetric?
With bulging or
moving?
 Symmetrical in shape

slightly full but not distended in older age

Scaphoid or flat in young group due to poor muscle tone or in
patients of normal weight subjects who are mildly overweight
 Appreciation of abdominal contours

Standing at the foot of

the table and looking up
towards the patient's
head.
Lower yourself until the
anterior abdominal
wall and ask the patient
to breathe normally while
you are doing so.
Appearance of the abdomen

Global
abdominal
enlargement is
usually caused
by air, fluid, or
fat.
Appearance of the abdomen

Localized
enlargement
probably distend
GB space
occupying lesion,
hepatomegaly.
 An aortic aneurysm
Palpable mass
Patient feeling of
pulsation
On rare occasions, a
lump can be visible.
 An aortic aneurysm
1 in 10 men over 65
may have some
enlargement of the
abdominal aorta.
About 1 in 100 will
have a large
aneurysm requiring
surgery.
 Appearance of the abdomen
(Skin)

Abnormal venous
patterns
Abnormal
discoloration
Umbilicus is sunken
 Striae
Stretch marks are a
light silver hue.
Pregnancy and obese
individuals
Cushings syndrome
(more purple or pink).
 Appearance of the abdomen
(Skin)
Tattoos
Scars can be drawn
on schematic
diagrams of the
abdomen (a picture is
worth a thousand
words).
 Cullens sign
Ecchymosis
periumbilically.
(intraperitoneal
hemorrhage
ruptured ectopic
pregnancy,
hemorrhagic
pancreatitis..)
 Grey-Turners sign
Ecchymosis of
flanks.
(retroperitoneal
hemorrhage
such as
hemorrhagic
pancreatitis)
Upward flow direction indicates IVC obstruction
SPIDER NEVI
Outward flow pattern from umbilicus in all directions ? Portal HTN
 Evaluate venous return states

Place index finger

side by side over a
vein and press
laterally, milking vein.
Release one finger
and time refill, repeat
with other finger.
Venous return is in
direction of faster
filling.
Appearance of the abdomen
Areas which
become more
pronounced when
the patient
valsalvas are
often associated
with ventral
hernias
 Visible Pulsations
More conspicuous in the In those with an aortic
thin than in the fat aneurysm and tortuous
Greater in the old than in aorta
the young. In those who have a
Increased in mass joining the aorta to
thyrotoxicosis, the anterior abdominal
hypertension, or aortic wall.
regurgitation)
Visible gastric Peristalsis Visible intestinal
Peristalsis
Gastric peristalsis is Intestinal peristalsis in
commonly seen in partial and chronic
neonates with intestinal obstruction
congenital Colonic obstruction is
hypertrophic pyloric usually not manifest
stenosis as visible peristalsis
 Appearance of the abdomen
Patient's movement

Patients with kidney

stones will frequently
writhe on the
examination table,
unable to find a
comfortable
position
 Appearance of the abdomen
Patient's movement

Patients with
peritonitis prefer to lie
very still as any
motion causes further
peritoneal irritation
and pain.
 2. AUSCULTATION
GUT SOUNDS

Use the diaphragm of your stethoscope to listen to gut sounds

Normal gut sounds are gurgling, 5 to 35 per minute
Borborygmi are loud, easily audible sounds. They are normal, too.
High pitched , tinkling (raindrops in a barrel) sounds are a sign of
early intestinal obstruction
Decreased sounds: (none for a minute) are a sign of decreased
gut activity. Gut sounds may be markedly decreased after
abdominal surgery; abdominal infection (peritonitis) or injury.
Absent Sounds : (no sounds for 5 minutes) are a bad sign. They
can be caused by longer-lasting intestinal obstruction, intestinal
perforation or intestinal (mesenteric) ischemia or infarction
 2. AUSCULTATION
Active bowel sounds 5-30/min
Hypoactive 4/min or less
Hyperactive 30 or more /min
Bruits
o A. Aorta
o B. Renal
o C. Iliac
Friction rub
Auscultation for bowel sounds

It is performed before percussion or

palpation
Auscultation for bowel sounds
Normal sounds are
due to peristaltic
activity.
Peristalsis: A
pregressice wavelike
movement that occurs
involuntarily in hollow
tubes of the body.
Auscultation for bowel sounds

Compared to the
cardiac and
pulmonary exams,
auscultation of the
abdomen has a
relatively minor role.
Auscultation for bowel sounds

Bowel sounds lend

supporting
information to other
findings but are not
pathognomonic
for any particular
process.
 Auscultation

1.Diaphragm of
stethoscope
used
2.Skin
depressed to
approximately 1
cm
 Auscultation

3.Listening in one
spot is usually
sufficient
4.Listening for 15-20
or 30-60 seconds
5.Bowel sounds cannot
be said to be absent
unless they are not heard
after listening for 3-5
minutes.
 Three things about bowel
sound
Are bowel sounds
present?
If present, are they
frequent or sparse
(i.e.quantity)?
What is the nature of
the sounds
(i.e.quality)?
 Bowel sound decrease

Inflammatory processes
of the serosa
After abdominal surgery
In response to narcotic
analgesics or
anesthesia.
Auscultation for bowel sounds

Inflammation of the
intestinal mucosa
will cause
hyperactive bowel
sounds.
Auscultation for bowel sounds
Processes which
lead to intestinal
obstruction initially
cause frequent
bowel sounds,
referred to as
"rushes."
 Auscultation for bowel
sounds
Processes which lead
to intestinal
obstruction initially
cause frequent bowel
sounds, referred to as
"rushes."
Auscultation for bowel sounds
Rushes" means
as the intestines
trying to force
their contents
through a tight
opening.
 Auscultation for bowel
sounds
Rushes" is followed
by decreased sound,
called "tinkles," and
then silence.
 Auscultation for bowel
sounds
After silence the
appearance of bowel
sounds marks the
return of intestinal
sounds activity, an
important phase of
the patient's recovery.
 Splash Sign

Splashing sound
indicative of air or
fluid in body cavity
with shaking
individual: normal in s
stomach.
Auscultation for bowel sounds
Bowel sounds,
then, must be
interpreted within
the context of the
particular clinical
situation.
 Bruits

Bruits confined
to systole do not
necessarily
indicate disease.
 Auscultation for vascular sounds
(bruits)
Aortic (midline between
umbilicus and xiphoid
Renal (two inches
superior to and two
inches lateral to
umbilicus)
Common iliac (midway
between umbilicus
and midpoint of
inguinal ligament)
Auscultation for vascular sounds
(bruits)

Presence of a bruit
on the renal artery
would lend
supporting
evidence for the
existence of renal
artery stenosis.
Auscultation for vascular sounds
(bruits)
When listening for
bruits, you will need
to press down quite
firmly as the renal
arteries are
retroperitoneal
structures.
 Venous Hum (rare)
Epigastric/umbilical
area.
Soft humming noises
in systolic/diastolic
component.
Indicates collateral
between portal and
venous systems as in
hepatic cirrhosis.
 Rubs Rubs-Rubs

Liver
Spleen
Cardiac
Pulmonary
 Friction rubs (rare)

Right and left upper

quandrants
Grating sound with
respiratory movement
Indicates
inflammation of the
capsule of the liver or
spleen (infection or
infarction).
 3. PERCUSSION
What it finds: liver size (kind of), spleen, fluid.
Percussing the body gives one of three notes:
Tympany is found in most of the abdomen,
caused by air in the gut. It has a higher pitch
than the lung.
Resonance is found in normal lung. It is lower
pitched and hollow.
Dullness is a flat sound, without echoes. The
liver and spleen, and fluid in the peritoneum
(ascites: ah-SY-teez), give a dull note.
A. Liver Span
Percuss downward from the chest in the right midclavicular line
until you detect the top edge of liver dullness.
Percuss upward from the abdomen in the same line until you detect
the bottom edge of liver dullness.
Measure the liver span between these two points. This
measurement should be 6-12 cm in a normal adult.

B. Splenic Dullness
Percuss the lowest costal interspace in the left anterior axillary
line. This area is normally tympanitic.
Ask the patient to take a deep breath and percuss this area again.
Dullness in this area is a sign of splenic enlargement.
 Percussion

Technique
Liver
Spleen
 Percussion (technique)

DIP joint of third

finger (pleximeter)
pressed firmly on the
abdomen remainder
of hand not touching
the abdomen
 Percussion (technique)
Striking hand
should move
only at the wrist,
with only little
more than force
of gravity
 Percussion (technique)
Middle finger of
striking hand
(plexor) should
knock the
pleximeter firmly,
with a strong
note
There are two basic sounds with
Percussion
Tympanitic
(drum-like)
sounds
produced by
percussing over
air filled
structures.
 There are two basic sounds with
Percussion

Dull sounds that

occur when a solid
structure (e.g. liver)
or fluid (e.g. ascites)
lies beneath the
region being
examined.
Examination of Liver (Percussion)

Midclavicular line
is noted
Second
intercostal space
is noted
 The two solid organs are
percussable in the normal patient
Liver: will be entirely
covered by the ribs.
Occasionally, an edge
may protrude 1-2
centimeter below the
costal margin.
Spleen: The spleen is
smaller and is entirely
protected by the ribs.
To determine the size of the liver
Measure the liver
span by percussing
hepatic dullness from
above (lung) and
below (bowel). A
normal liver span is 6
to 12 cm in the
midclavicular line.
To determine the size of the liver
Start just below the
right breast in a line
with the middle of
the clavicle.
Percussion in this
area should
produce a relatively
resonant note.
To determine the size of the liver
Move your hand
down a few
centimeters than
you will be over
the liver, which
will produce a
duller sounding
tone.
To determine the size of the liver
Continue
downward until
the sound
changes once
again. At this
point, you will
have reached the
inferior margin of
the liver.
Examination of Liver (Percussion)
Upper margin is
noted by first dull
percussion note
Lower margin is
noted by first
tympanitic note
To determine the size of the
liver
The resonant tone produced by
percussion over the anterior chest
wall will be somewhat less drum like
then that generated over the
intestines. While they are both
caused by tapping over air filled
structures, the ribs and pectoralis
muscle tend to dampen the sound.
 Examination of Spleen
(Percussion)
Percussion at Castells Spot
Castells Spot identified
Left anterior axillary line identified
Left lower costal margin identified
Percussion at Castells Spot while patient
inhales and exhales deeply

Dull tone indicates

possible
 Spleen percussion
Enlarged spleen
produce a dull
tone, in the left
upper quadrant
percussion but
should then be
verified by
palpation.
Shifting Dullness
This is a test for peritoneal fluid (ascites). ++
Percuss the patient's abdomen to outline areas of dullness and tympany.
Have the patient roll away from you.
Percuss and again outline areas of dullness and tympany. If the dullness has
shifted to areas of prior tympany, the patient may have excess peritoneal
fluid.

Psoas Sign
This is a test for appendicitis. ++
Place your hand above the patient's right knee.
Ask the patient to flex the right hip against resistance.
Increased abdominal pain indicates a positive psoas sign.

Obturator Sign
This is a test for appendicitis. ++
Raise the patient's right leg with the knee flexed.
Rotate the leg internally at the hip.
Increased abdominal pain indicates a positive obturator sign.
ILIOPSOAS TEST
 4. PALPATION
General Palpation
1. Begin with light palpation.
At this point you are mostly
looking for areas of
tenderness. The most
sensitive indicator of
tenderness is the patient's
facial expression (so watch
the patient's face, not your
hands). Voluntary or
involuntary guarding may
also be present.
2. Proceed to deep palpation
after surveying the abdomen
lightly. Try to identify
abdominal masses or areas
of deep tenderness
 Abdominal Palpation

Technique Spleen tip

Light Kidneys
Deep Aorta
Liver edge Masses
 Abdominal palpation
To palpate four
quadrants
superficially
from LLQ
counterclockwise
 Light Palpation
First warm your
hands by rubbing
them together before
placing them on the
patient.
Abdominal wall
depressed
approximately 1 cm
 Abdominal palpation
Use pads of three
fingers of one hand
and a light, gentle,
dipping maneuver to
examine abdomen
 Palpation (light)
Any areas of pain or
tenderness are
reserved for
evaluation at the end
of the exam
 Light Palpation
Mostly looking for
areas of tenderness
Tenderness is a
physical exam finding
a reflex occurs
(muscle splinting,
wide eyes, moaning,
teeth gritting).
 Palpation
Light palpation assesses
Muscle tone
Cutaneous
hypersensitivity
(suggests peritoneal
irritation)
 Palpation
Light palpation assesses
Presence of
superficial
(intramural) masses is
more prominent if
patient raises their
head ,Intra-abdominal
mass is less
prominent if patient
raises their head
 Palpation (deep)

Entire palm
Either one- or
two handed
technique is
acceptable
 Deep Palpation
Use palmar surface of
fingers of one hand
(greatest number of
fingers) and a deep,
firm, gentle maneuver
to examine abdomen
 Palpation

Palpate deeply with

finger pads (do not
dig in with finger
tips)
 Deep Palpation
Palpate tender areas
last
Try to identify
abdominal masses or
areas of deep
tenderness
 Two handed technique
When deep
palpation is
difficult, examiner
may want to use
left hand placed
over right hand to
help exert pressure
 Palpation (deep)

Push as deeply as
patient will allow
without significant
discomfort
 Normal structure that may be
palpable
Sigmoid colon Distended bladder
Liver Gravid and non-
Kidney gravid uterus
Abdominal aorta Xyphoid process
Iliac artery spleen
 Abdominal mass
Intra abdominal
masses or
enlargements of the
liver, gallbladder or
spleen
Abdominal wall mass
 Intra abdominal masses or enlargements of
the liver, gallbladder or spleen
They will shift down
with inspiration and
back with expiration.
(not true of masses
within the abdominal
wall or retroperitoneal
structures).
 Aabdominal wall mass
It will become more
evident and palpable
when patient flexes
neck as this contracts
rectus muscles.
Paraumbilical node
 Type of abdominal pain

Visceral pain Somatic pain

 Visceral pain
This is pain that arises
from an organic lesion
or functional
disturbance within an
abdominal viscus
(dull, poorly
localized, and
difficult for the
patient to
characterize).
 Somatic pain
Painful lesion of the
skin
Sharp, bright, and
well localized
Indicates
involvement of
parietal peritoneum
or the abdominal
wall itself
 Tenderness
If there is tenderness
determine the point of
maximum tenderness
and its distribution
 Abdominal muscle spasm
Voluntary guarding Involuntary guarding
Tensing abdominal Muscular spasm or
muscles due to rigidity due to
patient anxiety, peritoneal
ticklishness, or inflammation
toprevent palpation to May be localized
a painful area (early appendicitis )or
diffuse (perforated
bowel)
 Board-like rigidity
If abdominal wall is
palpated as obviously
tense, even as rigid
as a board, board-like
rigidity is so called. Is
caused by the spasm
of abdominal muscle
due to peritoneal
irritation.
Differential diagnosis of abdominal
pain
Spine pain
Abdominal wall
pain( differentiated by
having the patient
tense his abdominal
muscles, by forcefully
elevating his head
while keeping his
shoulders flat on the
table)
 Liver palpation
(Standard Method)
Start in the RUQ,10
centimeters below the
rib margin in the mid-
clavicular line
Place left hand
posteriorly parallel to
and supporting 11th &
12th ribs on right.
Standard Method Liver palpation

Ask the patient to

take a deep breath.
You may feel the
edge of the liver press
against your fingers.
 Liver palpation
(Standard Method)

Palpating hand is
held steady while
patient inhales
 Liver palpation
(Standard Method)
Palpating hand is
lifted and moved
while the patient
breathes out
 Liver palpation
Another method of
palpating the liver
uses the radial border
of the index finger. In
this method the
anterior hand is
placed flat on the
anterior abdominal
wall with fingers
parallel to the costal
margin
Alternate Method Liver palpation

Is useful when the

patient is obese or
when the examiner
is small compared
to the patient.
Alternate Method Liver palpation

Stand by the patient's

chest.
"Hook" your fingers
just below the costal
margin and press
firmly.
 Hepatomegaly
More than 1cm below
the costal margin
An exception is a
congenitally large
right lobe of the liver
Severe, chronic
emphysema
Pulsation transmitted from aorta Tricuspid valve insufficiency
 Hepatojugular reflux
sign
If you press the liver,
you will find the
dilated jugular vein
becomes more
bulged or distended,
as from the
enlargement of liver
passive congestion
resulted from right
failure.
Ballotable sign
 Palpation of the Liver
Standard Method
Place your fingers just below the right costal
margin and press firmly.
Ask the patient to take a deep breath.
You may feel the edge of the liver press
against your fingers. Or it may slide under
your hand as the patient exhales. A normal
liver is not tender.

Alternate Method
This method is useful when the patient is
obese or when the examiner is small
compared to the patient.
Stand by the patient's chest.
"Hook" your fingers just below the costal
margin and press firmly.
Ask the patient to take a deep breath.
You may feel the edge of the liver press
against your fingers.
 Spleen palpation

Seldom palpable in
normal adults.
Causes include
COPD, and deep
inspiratory descent of
the diaphragm.
 Spleen palpation

Support lower left rib

cage with left hand
while patient is supine
and lift anteriorly on
the rib cage.
 Spleen palpation

Palpate upwards
toward spleen with
finger tips of right
hand, starting below
left costal margin.
Have the patient take
a deep breath.
 Examination of Spleen
(Palpation)

Deep technique used

Starting point is RLQ,
proceeding to LUQ
 Kidney palpation
Place left hand
posteriorly just below
the right 12th rib. Lift
upwards.
Palpate deeply with
right hand on anterior
abdominal wall.
 Examination of Kidney
Patient take a deep
breath.
Feel lower pole of
kidney and try to
capture it between
your hands.
 Examination of Kidney

Right kidney may be felt to slip between hands

during exhalation
 Examination of Aorta

Flat palm placed

over the the
epigastrium to
locate pulse
 Examination of Aorta
Press down deeply in
the midline above the
umbilicus.
The aortic pulsation is
easily felt on most
individuals.
 Examination of Aorta

Hands then oriented

vertically on either
side of midline with
distal fingers at level
of pulsation; equal
pressure applied until
pulsation is palpated

A well defined, pulsatile mass, greater than 3 cm

across, suggests an aortic aneurysm.
 Examination of Aorta

Lateral width of pulsation is determined by space

between index fingers
PEMERIKSAAN ABDOMEN

Special exam
 Special exam
Murphys Sign Re bound
McBurneys Tenderness
Point Costovertebral
Rovsings Sign tenderness
Psoas Sign Shifting
Obturator Dullness
Sign Fluid wave
Murphys Sign (acute cholecystitis)

Examiners hand is at
middle inferior border
of liver.
Patient is asked to
take deep inspiration.
If positive patient will
experience pain and
will stop short of full
inspiration
Hepatitis, subdiaphragmatic
abscess Cholecystitis
 McBurneys Point

Localized tenderness
Just below midpoint
of line between right
anterior iliac crest and
umbilicus.
Heel strike, riding
over bumps in road
while driving,
coughing, will
produce pain.
McBurneys Point (Common Causes)
Appendicitis
Incarcerated or
strangulated hernia
Ovarian torsion (twisted
Fallopian tube)
Pelvic inflammatory disea
se

Abdominal abscess
Hepatitis
Diverticular disease
Meckel''s diverticulum
 Rovsings Sign

Patient will
experience right lower
quadrant pain (in
region of McBurneys
Point) when left lower
quadrant is palpated.
 Non-Classical Appendicitis

Iliopsoas Sign

Obturator Sign
 Iliopsoas Sign

Patient can lay on side and extend leg at the hip

or have patient lay on back and try to flex hip
against the resistance of examiners hand on
thigh. If patient has an inflamed retrocecal
appendix, this will produce pain.
 Iliopsoas Sign
Anatomic basis for
the psoas sign:
inflamed appendix is
in a retroperitoneal
location in contact
with the psoas
muscle, which is
stretched by this
maneuver.
 Obturator Sign

Internally rotate right leg at the hip with the knee

at 90 degrees of flexion. Will produce pain if
 Obturator Sign
Anatomic basis for
the obturator sign:
inflamed appendix in
the pelvis is in contact
with the obturator
internus muscle,
which is stretched by
this maneuver.
 Rebound Tenderness
(For peritoneal irritation)

Warn the patient what

you are about to do.
Press deeply on the
abdomen with your hand.
After a moment, quickly
release pressure.
If it hurts more when you
release, the patient has
rebound tenderness. [4]
 Cost vertebral Tenderness
(Often with renal disease)
Use the heel of your
closed fist to strike
the patient firmly
over the
costovertebral
angles.
Compare the left
and right sides.
Warn the patient Patient sit up on the exam table
 Shifting Dullness
(For peritoneal fluid)

Percuss from anterior

abdomen laterally to
outline areas of
dullness noted
 Examination for Shifting
Dullness
Patient rolled slightly
toward the examined
side; movement of the
dull point medially is
described as shifting
dullness and
suggests ascites
Shifting Dullness
Fluid wave
 CONTRAINDICATIONS FOR
ABDOMINAL ASSESSMENT
NEVER PALPATE IF SUSPECTED
APPENDICITIS OR DISSECTING ABD.
AORTIC ANEURSYM
NEVER PALPATE WITH POLYCYSTIC
KIDNEYS
DO NOT PALPATE OF PERCUSS
TRANSPLANTED ORGANS