00:01
So, having talked about some of
those specific disease pathologies,
it's time to talk about the
assessment of abdominal pain itself.
00:08
There are many patients who come in
with abdominal pain
and the trick with
physical diagnosis is to determine
whether this person has a
benign cause of abdominal pain
such as
irritable bowel syndrome,
or maybe even just constipation
versus something intense, you know,
something really severe
like a perforated appendicitis,
for example.
00:28
Patients with abdominal pain
can again either have
benign causes,
abdominal wall pain that causes
simply a painful tender organ,
like an example of diverticulitis,
and then a perforated viscous
causing peritonitis.
00:43
The last, the latter of which,
of course, is a surgical emergency,
and is something
we don't want to miss.
00:52
All patients may have
tenderness on exam
and all the circumstances
that I just described,
and all of them may have
voluntary guarding,
which is, you know,
if there's a tender organ in there,
the patient does not want me
pushing on it.
01:03
So they're going to contract
their abdominal wall muscles.
01:06
The astute clinician, however,
can distinguish between
voluntary guarding
and involuntary rigidity.
01:14
So rigidity is when, there's so
much inflammation in the belly
and in the peritoneum,
that it's causing
reflex muscle spasm
that the patient
has no control over.
01:24
So, it's important for us to try
and tease apart what's going on
because obviously,
with actual rigidity
and acute abdomen,
we need to get surgery involved.
01:32
So ways to do this are as follows.
01:34
Number one,
as I said before,
we would have her
flexure hips a little bit
just to relax the
abdominal musculature.
01:39
But for the purposes
of what we're doing now,
I'll leave her legs down.
01:44
Next up, it's good to start
palpating the abdomen,
even before the patient knows
you're palpating the abdomen.
01:50
And what I mean by that is,
I'm going to have my stethoscope on
back when I was auscultating,
I'll be talking to my patient:
Asking her about where she's from?
Asking her what
she does for a living?
Talking to her,
you know, telling jokes,
asking her about
her family, whatever.
02:06
And I've just done
my palpation exam
without her even knowing it.
02:10
Now, it sounds like I'm being
disingenuous or slippery there,
but it's important to distinguish
between so called
distractible tenderness,
versus real intense tenderness,
where even if I'm talking to her
about something unrelated
to why she's here today,
if she feels every motion
of my hand,
and she's complaining of pain
and asking me to stop,
I know that's real tenderness.
02:33
And likewise,
if her abdomen does not relax
throughout that gentle prodding
with my stethoscope,
that tells me that rigidity
real, real actual involuntary
rigidity may be at play.
02:46
So, having said that,
let's look at a few tests
for specific types
of painful pathologies
in the abdomen,
starting with
acute cholecystitis.
02:54
Anyone who's had any degree
of medical training
knows about Murphy sign,
and yet a lot of folks sometimes
performing incorrectly.
03:03
So Murphy sign is based on the idea
that the gallbladder is inflamed.
03:07
But when she is in exhalation,
the diaphragm is higher
and the liver,
and the gallbladder
are therefore higher up
in the abdomen,
and towards the thorax.
03:17
I'm going to put my fingers
down in this area now.
03:19
And then I'm going to have
the patient take a deep breath.
03:22
So take a deep breath for me.
03:24
Now, if while taking a deep breath,
which again,
her diaphragm is lowering
the liver and the gallbladder
towards my insulting fingers,
if she abruptly stops
taking that deep breath,
that is the Murphy sign.
03:37
It basically is indication that
by bringing her gallbladder
slowly towards my fingers,
if it arrests her breath,
then it suggests the presence of
acute cholecystitis.
03:50
Classically, you hear
sonographic Murphy's,
that's when the ultrasonographer
is doing the exact same thing
and has the patient
take a deep breath,
and that is also particularly
a positive sign for
acute cholecystitis.
04:02
Next up,
for acute appendicitis.
04:04
There are many different signs
that people have talked about
for acute appendicitis
and most noteworthy ones
that have good data behind them
is McBurney's point.
04:12
These are,
basically there's a line drawn
between the anterior superior
iliac spine and the umbilicus.
04:19
And about two thirds of the way
from the umbilicus
to the anterior superior iliac
spine is McBurney's point,
which was hypothesized
to be the place where
you're most likely
to detect appendicitis.
04:30
If a patient has point tenderness
right in that spot
that support the
diagnosis of appendicitis.
04:36
Rovsing's sign is the idea
that if I push on this side,
and it causes pain over here,
that also supports appendicitis,
though somewhat less strongly.
04:44
And then the Psoas sign,
named after the iliopsoas muscle
is also helpful.
04:49
So, I'm going to have you roll over
on your left hip now, please.
04:54
Since the appendix often lies
just on top of the psoas muscle,
if I can strain
the psoas muscle
where there may be some
periappendiceal inflammation
that could also
support the diagnosis.
05:08
So, I'm simply going to take
her leg and fully extend it.
05:11
So, I'm stretching her psoas muscle
when I do this,
and if that's elicits pain
in that area
around where
McBurney's point was
that would support the diagnosis
of appendicitis as well.
05:21
You can lie back
on your back now.