So in the exam we wanna go through a few steps.
So step one in the physical exam is the vital signs.
Vitals are vital.
You probably have heard me say that
if you’ve listened to some of these other lectures.
You wanna make sure you have a full set of vital signs on your patient.
Sometimes it can be easy that one of them maybe overlooked a little bit
but definitely having an accurate temperature reading,
a blood pressure reading, a pulse oximeter, a heart rate and a respiratory rate.
All will benefit you in this situation
and you wanna make sure you're paying attention to all of those vital signs.
Step two is to inspect.
So is the patient laying still or are they restless?
Are there any prior surgical scars on their abdomen?
Similar to when a patient comes in with a respiratory distress,
there's a lot of information you can get just by looking at your patient.
If they’re laying still that can potentially indicated they have peritoneal signs.
Them moving around might make their pain a little bit worse.
If the patient is restless, that might support renal colic, or a kidney stone diagnosis
classically those patient are very restless.
Some patients also aren’t very good at remembering
what procedures they’ve had on their abdomen
and some patients might, you might ask them I’ve had the situation for sure,
“Have you ever had any surgeries on your abdomen?”
And they say no and then you look at their belly and there’s lots of scars there.
So in those situations you wanna go ahead
and maybe ask some of a little bit more approving details.
If you see surgical scars or look in the medical record
to try and figure out what happened.
Surgical scars are becoming harder and harder to necessarily notice
especially with more and more people getting laparoscopic surgery.
Cause those laparoscopic surgical scars are very very small
and are often try to do them in less noticeable areas.
So one classic places are just around the umbilicus
and those can be a little bit harder to pick up on.
Step three is to listen.
Historically, everyone’s taught to listen before you palpate.
So go ahead and go with that for now.
You wanna listen for two minutes and you're listening for bowel sounds.
If you don't hear any bowel sounds after a full two minutes,
the patient does not have bowel sounds likely.
So, you wanna make sure you're listening for that appropriate time period
and you’re hearing if the bowel sounds are overactive, underactive, not present at all,
or potentially in the normal range.
Step four is palpation.
You wanna start in the area away from the pain.
So if the patient's pain is on the right side in the lower abdomen,
go ahead and start on the left upper abdomen
and then work your way around to that area.
You’re gonna wanna palpate lightly
and then go ahead and push a little bit more deeply
depending on the exam that you’re getting for the patient.
When you're palpating you also wanna go ahead
and access for rebound tenderness.
So rebound tenderness is basically pain that occurs when you let go.
So basically you push down on the abdomen
and when you release your hand, I tell people to try and focus
does it hurt more when I push down?
Or does it hurt more when I let go?
Rebound tenderness is potentially supportive of the patient
more likely having a surgical process.
The other things you can do to access for rebound tenderness
is that you can sometimes shake the bed.
This was a tip that I learned actually when I was a medical student
from one of my surgery residents.
And he would go to rooms for patients that were being worked up.
And he would basically take his knee and he would nudges the bed
a little bit and see if the patient reacted.
Shaking of the bed reproducing abdominal pain
is again, something that indicates that the patient may have
peritoneal irritation and possibly a surgical process.
The other thing that you can do and this is more commonly done
in the pediatric population is you can get your patient up out of bed
and you can have them jump on one foot.
Again, that’s something that indicates that if they have pain
that’s reproduced in that situation, then the patient may have
more likely to have appendicitis or a surgical process.
This is a classic thing in pediatrics that they get their patient up
and have them jump on one foot and if the kid’s willing to
or able to do it without pain, a lot of pediatric ED people will say
that the likelihood of appendicitis is far less likely.
The other thing that I do sometimes ask patients is I have them
estimate when they came to the emergency department
in their car, if going over bumps bother them.
Again, it's an element of just that little shaking movement or vibrations
causing or making that pain worse.
There are some additional exam maneuvers that you wanna
think about doing.
So one of them is Murphy’s sign and that is taking a closer look
at the gallbladder kind of indicating if there is a disease
in the gallbladder for cholecystitis, and what you do in that situation
is you feel in the right upper quadrant and when you're palpitating
deeply in the right upper quadrant the patient stops inspiring
and that’s indicating that that pain is so severe or intense or localized to that area
that the patient will stop inspiring.
This is something that can be done on physical exam
and also can be done during an ultrasound exam.
So when you’re doing the ultrasound for the patient,
you can see if they have a positive Murphy’s.
The other thing you can do and this is generally done in the center
of the abdomen is you can palpate the aorta.
You wanna think about AAA in older patients.
So as patients are older is when this disease process
generally does start to develop.
So for those patients you wanna go ahead and feel the center of the belly
and see if you feel any kind of larger palpable mass.
In skinny younger people you actually maybe able to feel their aorta
because they're generally skinny and younger,
and you’re able to feel it in the center of their abdomen.
Other maneuvers are the psoas, obturator, and Rovsing's sign.
Those are indicative of appendicitis
and we’ll talk more about those when we discuss appendicitis further.
The other things to focus on are genitourinary exams,
the testicular exam and the pelvic exam.
The testicular exam is especially important for the patient
who your concern may not necessarily be able to accurately report to you
whether or not they are having testicular pain.
The pelvic exam I always tell women when they come to the ED with abdominal pain
that they're really quite tricky because in addition to having your intestines
and the normal stuff in your belly you also have your reproductive organs.
So you have the uterus and ovaries
and those are sometimes the source of the pain.
So doing a pelvic exam for all women who have uterus and ovaries
is a key thing to do when they present with abdominal pain
because you don't wanna miss the pelvic infection or some kind of
ovarian mass that's presenting in that way.
You also wanna look for any kind of extra abdominal findings.
So that means that the herpes zoster rash that was discussed.
It means listening to the patient’s lungs and seeing if there's any
concern for pneumonia.
Looking at the respiratory rate and seeing if the respiratory rate is elevated,
that might make you support on diabetic ketoacidosis.
If you're worried about glaucoma, examining the face and eyes.