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Physical Examinations II

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Abdominal Exam III: Palpation

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Skillful abdominal palpation allows for examination of the large and relatively superficial organs, and some of the smaller and deeper structures as well. This technique provides valuable information regarding localization of the problem and its severity as it identifies the areas of tenderness as well as the presence of organomegaly and tumors.

In Abdominal Exam Part I, we focused on inspection and auscultation. In Part II, we discussed the essential percussion steps for assessing various abdominal structures. Here, we'll discuss the importance of the different types of abdominal palpation followed by a review of the steps a clinician should perform to evaluate different abdominal structures.

Basically, there are two types, light and deep palpation. As the name suggests, light palpation is more superficial and therefore it permits identification of the superficial organs or masses, and sometimes it can detect abdominal wall crepitus.

On the other hand, deep palpation allows examination of organs including the liver, caecum. sigmoid colon and, sometimes, transverse colon, and stomach. Deep palpation can also help detect enlarged kidneys, gall bladder and spleen, as, in a healthy state, these organs are rarely palpable. In addition, it can help in diagnosis of aortic aneurysm. With this background information, let's see how to perform a comprehensive abdominal palpation exam.

First, we'll go over the light palpation steps. Make sure that the patient is positioned correctly. Explain the procedure and obtain the patient's consent before starting the exam. Drape the patient in a way that maintains their modesty, but doesn't compromise the exam. Ask the patient to indicate the area of pain or tenderness. Make a note of this, and examine this area last, to avoid abdominal resistance due to apprehension. To improve the abdominal relaxation, you can ask the patient to bend their knees. You might also need to ask the patient to breathe with their abdomen, while placing your hand on it and trying to palpate. These measures usually decrease voluntary guarding.

For light palpation, use your dominant hand, keep your fingers together and press to a depth of approximately 1 cm using the finger pads with a gentle circular motion. Slightly lift your hand as you move to a different spot and avoid sudden jabs. Examine all of the abdominal regions, moving in a clockwise or anti-clockwise direction. As you palpate, watch the patient's face for any signs of discomfort or pain. Also note irregularities of the abdominal wall, superficial organs or masses, and crepitus if present.

Now let's go over the steps for deep palpation, which permits assessment of the internal organs and delineation of the intra-abdominal masses. Again, always start with the quadrant where the patient is not experiencing any pain.

Place the flat of your hand on the abdominal wall and apply firm pressure downward and longitudinally. Keep your fingers relatively fixed on the skin and use the rolling motion. Continue watching the patient's face for the signs of pain or discomfort as you proceed. In obese patients or if voluntary muscle resistance is present, use the two-hand palpation technique. For this, place your non-dominant hand on the top of your dominant hand. Keep the lower hand relaxed and press with the fingers of the upper hand on the distal phalangeal joints of the lower hand. This way one hand produces the pressure while the other is used to feel.

After these general palpation steps, let's see how to perform liver palpation. Place your right hand lateral to the rectus muscle, well below the level of percussed border of liver dullness, and orient your fingers cephalad, slightly tilted towards the midline. Ask the patient to take a deep breath. On inspiration the liver descends and its edge meets fingertips of the palpating hand. Continue moving upwards until you feel the liver edge, which is usually a few cm below the right costal margin. Note the edge's texture and regularity. When your fingers meet the liver edge, slightly reduce the pressure on the abdominal wall while the patient is still taking a deep breath in. This maneuver allows the examiner to feel anterior liver surface as it slips under the finger pads. Make a note of the consistency of the liver surface. For bimanual liver palpation, place the left hand posteriorly at the level of the two lower ribs and gently press upward to elevate the liver into a more accessible position. Ask the patient to take a deep breath and perform palpation with the right hand as demonstrated previously. Sometimes, the liver is not palpable by these standard techniques and therefore a different maneuver like "hooking" can prove to be helpful. To perform this technique, place your flexed fingers over the edge of costal margin. Ask the patient to take a deep breath and try to feel the liver edge as you press downward and upward, towards the patient's head.

Next, perform spleen palpation. A normal size spleen is rarely palpable. However, if the spleen is significantly enlarged, it displaces the stomach and expands downward below the rib cage and medially across the abdomen, and might be felt as low as at the left lower quadrant. In order to detect enlarged spleen, request the patient to take a deep breath and starting in left lower quadrant, move your fingers slightly up with each inspiration and expiration. Palpate pressing down and towards the patient's head and then releasing, in the same motion as for palpating of the lower edge of the liver. If the spleen is not felt, repeat the exam with patient lying on their right side. Some examiners use the bimanual spleen palpation technique, during which the palpation is performed with the right hand, while the left the hand is placed behind the left rib cage, and is pressed on the ribs and soft tissues upwards.

Lastly, palpate to detect enlarged kidneys. Ask the patient to take a deep breath, keep your left hand positioned at the costophrenic angle and palpate with your right hand pressing forward. Attempt to capture the kidney between your hands, or at least feel it with your upper hand. If you feel the kidney on inspiration, ask the patient to exhale deeply and hold their breath for a moment. You might feel the kidney moving back to its expiratory position. Repeat the maneuver on the left side. At the end of the exam, thank the patient for their cooperation.

You've just watched the JoVE Clinical Skills video on abdominal palpation. In this presentation, we reviewed the types of palpation techniques useful in evaluation of various abdominal structures. This part of physical diagnosis is especially informative when evaluating a patient presenting abdominal pain, as it provides insight into localization, cause, and severity of the problem. As always, thanks for watching!

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