THE ABDOMEN SELECTED TOPICS

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THE ABDOMEN SELECTED TOPICS R. MICHAEL
RODRIGUEZ, M.D. ASSOCIATE PROFESSOR OF
MEDICINE VANDERBILT UNIVERSITY SCHOOL OF MEDICINE
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THE GALLBLADDER
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MALIGNANCY COURVOISIERS SIGN A PALPABLE
NONTENDER GALL BLADDER IN A PATIENT WITH JAUNDICE
SUGGESTING EXTRAHEPATIC OBSTRUCTUON OF THE
BILIARY SYSTEM SECONDARY TO MALIGNANCY (ORIGINAL
DESCRIPTION). CHOLECYSTITIS MURPHYS SIGN WITH
THE EXAMINERS FINGERS POSITIONED ALONG THE
INFERIOR BORDER OF THE LIVER IN THE RIGHT COSTAL
ARCH THE PATIENT IS ALLOWED TO INSPIRE. DURING
INSPIRATION THE INFLAMED GALLBLADDER TOUCHES THE
EXAMINERS FINGERS RESULTING IN THE SUDDEN
CESSATION OF INSPIRATION. BOAS SIGN
HYPERESTHESIA AND REFERRED PAIN TO THE RIGHT
COSTOPHRENIC ANGLE IN PATIENTS WITH ACUTE
CHOLECYSTITIS.
JAMA 1968204165 J EMER MED 1986457-63
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PERITONITIS
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PERITONITIS THE EXAM

• GUARDING
• REBOUND TENDERNESS
• COUGH TEST
• CARNETTS SIGN ABDOMINAL WALL TENDERNESS TEST

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GUARDING VOLUNTARY CONTRACTION OF THE ABDOMINAL
WALL MUSCULATURE. RIGIDITY INVOLUNTARY CONTOL
OF THE ABDOMINAL WALL MUSCULATURE. REBOUND
TENDERNESS (BLUMBERGS SIGN) THE CLINICIAN
MAINTAINS HAND PRESSURE OVER AN AREA OF
TENDERNESS. THE CLINICIAN THEN RELEASES THE HAND
PRESSURE SUDDENLY. PAIN DENOTES A POSITIVE TEST.
MANY OF US DO NOT RECOMMEND THIS EXAM DUE TO THE
DISCOMFORT TO THE PATIENT WHO ALREADY HAS
LOCALIZED GUARDING. COUGH TEST IF A PATIENT HAS
PERITONITIS, ANY MOVEMENT OF THE ABDOMEN WILL
ELICIT PAIN. THEREFORE A COUGH IN A PATIENT WITH
PERITONITIS WILL PRECIPITATE PAIN (POSITIVE
TEST). ABDOMINAL WALL TENDERNESS TEST (CARNETTS
SIGN) HELPS TO DISTINGUISH BETWEEN LESIONS OF
THE ABDOMINAL WALL WHICH CAUSE PAIN AND
PERITONITIS. THE EXAMINER IDENTIFIES THE AREA OF
TENDERNESS AND APPLIES MODERATE PRESSURE. THE
PATIENT IS ASKED TO LIFT THEIR HEAD AND
SHOULDERS. IF THE PAIN IS INCREASED, THE TEST IS
POSITIVE (PATIENT HAS A LESION OF THE ABDOMINAL
WALL NOT PERITONITIS). PATIENTS WITH PERITONITIS
SHOULD HAVE DECREASED PAIN DUE TO THE TENSE
ABDOMINAL WALL.
HAMILTON BAILEYS DEMONSTRATIONS OF PHYSICAL
SIGNS IN CLINICAL SURGERY, 1986, WRIGHT THE EARLY
DIAGNOSIS OF THE ACUTE ABDOMEN, LONDON, 1972,
OXFORD UNIVERSITY PRESS BR MED J 19943081336
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OBTURATOR AND PSOAS SIGN
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PSOAS SIGN
PRINCIPLE - STRETCH OF PELVIC MUSCULATURE
(ILIOPSOAS MUSCLE) WILL ELICIT PAIN. ROLL THE
PATIENT ON THEIR LEFT SIDE AND HYPEREXTEND THE
RIGHT HIP. PAIN WITH EXTENSION IS A POSITIVE SIGN
COPES EARLY DIAGNOSIS OF THE ACUTE ABDOMEN, 19TH
ED. OXFORD UNIVERSITY PRESS, 1996
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OBTURATOR SIGN
PRINCIPLE SAME AS PSOAS SIGN. THE EXAMINER
FLEXES THE PATIENTS RIGHT HIP AND INTERNALLY
ROTATES THE RIGHT HIP. PAIN WITH INTERNAL
ROTATION IS A POSITIVE SIGN.
COPES EARLY DIAGNOSIS OF THE ACUTE ABDOMEN, 19TH
ED. OXFORD UNIVERSITY PRESS, 1996
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APPENDICITIS
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APPENDICITIS THE EXAM

• ROVSINGS SIGN
• PSOAS SIGN
• OBTURATOR SIGN
• RECTAL TENDERNESS
• MC BURNEYS POINT TENDERNESS

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ROVSINGS SIGN ALSO KNOW AS INDIRECT
TENDERNESS. THE SIGN IS POSITIVE WHEN PRESSURE
APPLIED TO THE LEFT LOWER QUADRANT RESULTS IN
RIGHT LOWER QUADRANT PAIN. PSOAS SIGN SEE
PREVIOUS SLIDES. OBTURATOR SIGN SEE PREVIOUS
SLIDES. RECTAL TENDERNESS PATIENTS WITH
APPENDICITIS INVOLVIN/G THE PELVIS MAY HAVE
RECTAL TENDERNESS ON EXAMINATION. MC BURNEYS
POINT TENDERNESS A POINT 1½ -2 INCHES FROM THE
ANTERIOR SUPERIOR SPINOUS PROCESS OF THE ILEUM ON
A STRAIGHT LINE DRAWN FROM THAT PROCESS TO THE
UMBILICUS. IN 1889 CHARLES MCBURNEY STATED THAT
ALL PATIENTS WITH APPENDICITIS HAD MAXIMAL PAIN
AT THIS POINT.
J EMERG MED 1986457-63 HAMILTON BAILEYS
DEMONSTRATIONS OF PHYSICAL SIGNS IN CLINICAL
SURGERY, BRISTOL, 1986, WRIGHT
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ABDOMINAL AORTIC ANEURYSM
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ABDOMINAL AORTIC ANEURYSM THE EXAM
METHOD THE PATIENTS ABDOMEN SHOULD BE RELAXED
WITH THE KNEES FLEXED. THE EXAMINER FEELS
CEPHALAD OF THE UMBILICUS FOR THE AORTIC
PULSATION. PLACE BOTH HANDS ON THE ABDOMEN WITH
THE INDEX FINGER ON EITHER SIDE OF THE PULSATING
AORTA. ESTIMATE THE WIDTH ( NL lt2.5CM IN WIDTH).
JAMA 199928177-81 BATES 8TH ED, 2003