Acute Abdomen: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

  • General physical examination – including blood pressure, pulse, body weight, height; further:
    • Inspection (viewing).
      • Skin, mucous membranes, and sclerae (white part of the eye) [jaundice/ jaundice].
      • Abdomen (abdomen)
        • Shape of the abdomen?
        • Skin color? Skin texture?
        • Efflorescences (skin changes)?
        • Pulsations? Bowel movements?
        • Visible vessels?
        • Scars? Hernias (fractures)?
      • Gait pattern (fluid, limping).
      • Body posture (upright, bent over, relieving posture).
        • Tightened legs [indication of inflammation].
        • Rolling back and forth [typical colic behavior].
    • Auscultation (listening) of the heart [see under differential diagnoses: cardiovascular system].
    • Examination of the lungs
      • Auscultation of the lungs [see under differential diagnoses: respiratory system].
      • Bronchophony (checking the conduction of high-frequency sounds; the patient is asked to pronounce the word “66” several times in a pointed voice while the physician listens to the lungs)[increased sound conduction due to pulmonary infiltration/compaction of lung tissue (e.g. e.g. in pneumonia) the consequence is, the number “66” is better understood on the diseased side than on the healthy side; in case of decreased sound conduction (attenuated or absent: e.g. in pleural effusion, pneumothorax, emphysema). The result is, the number “66” is barely audible to absent over the diseased part of the lung, because the high-frequency sounds are strongly attenuated]
      • Percussion (tapping) of the lungs [e.g., in emphysema; box tone in pneumothorax]
      • Vocal fremitus (checking the conduction of low frequencies; the patient is asked to pronounce the word “99” several times in a low voice while the physician places his hands on the patient’s chest or back)[increased sound conduction due to pulmonary infiltration/compaction of lung tissue (e. e.g. in pneumonia) the consequence is, the number “99” is better understood on the diseased side than on the healthy side; in case of reduced sound conduction (attenuated: e.g. atelectasis, pleural rind; strongly attenuated or absent: in case of pleural effusion, pneumothorax, pulmonary emphysema). The result is, the number “99” is barely audible to absent over the diseased part of the lung, because the low-frequency sounds are strongly attenuated]
    • Examination of the abdomen
      • Auscultation of the abdomen [vascular or stenotic sounds?, bowel sounds?]
      • Percussion (tapping) of the abdomen:
        • [Ascites (abdominal fluid): phenomenon of the fluctuation wave. This can be triggered as follows: tapping against one flank will transmit a wave of fluid to the other flank, which can be felt by placing the hand on it; flank attenuation.
        • Cholelithiasis (gallstones) or cholecystitis (gallbladder inflammation): tapping pain over the gallbladder region and the lower right ribcage.
        • Meteorism (flatulence): hypersonoric tapping sound.
        • Attenuation of the knock due to enlarged liver or spleen, tumor, urinary retention.
        • Hepatomegaly (liver enlargement) and/or splenomegaly (spleen enlargement): estimate liver and spleen size.
      • Palpation (palpation) of the abdomen (tenderness?, palpation pain?, release pain?, cough pain?, guarding pain?, bowel sounds?, hernial orifices?, renal bearing palpation pain?) [colic pain?, perforation pain? or inflammatory pain? ; localization of pain using the 4-quadrant principle].
        • [Peritonitis (inflammation of the peritoneum): direct or indirect palpation dolence (tenderness) and severe tenderness to touch?
        • Enlarged and palpable liver?
        • Pain at McBurney’s pressure point/psoas sign (appendicitis/illness)?]
    • Digital rectal examination (DRU): examination of the rectum (rectum) and adjacent organs with the finger by palpation [leading symptoms: Hematochezia; melena – by blood admixtures abnormally black colored, usually also malodorous and shiny stool; polyp?, carcinoma? ; Douglas pain in inflammation in the pelvis?]
  • Gynecological examination [due todifferential diagnoses:
    • Adnexitis – inflammation of the fallopian tubes and ovary.
    • Dysmenorrhea (period pain)
    • Endometriosis – occurrence of endometrium outside the endometrial layer of the uterus.
    • Extrauterine pregnancy – pregnancy outside the uterus; extrauterine pregnancy is present in approximately 1 to 2% of all pregnancies: Tubargravidity (tubal pregnancy), ovariangravidity (pregnancy in the ovary), peritonealgravidity or abdominalgravidity (abdominal pregnancy), cervicalgravidity (pregnancy in the cervix).
    • Mid-cycle pain (intermenstrual pain) – lower abdominal pain occurring in the middle of the woman’s cycle, probably due to follicular rupture.
    • Ovarian cyst, pedunculated – water-filled tumor in the region of the ovary, whose supplying vessels have been pinched off]
  • Neurological examination [due todifferential diagnoses:
    • Epilepsy equivalent
    • Compression of the spinal cord/spinal nerves.
    • Meningitis (meningitis)
    • Neuralgia – pain in the area of spread of a sensitive nerve without a demonstrable cause.
    • Nerve root irritation syndrome
    • Radiculitis (nerve root inflammation)
    • Tabes dorsalis (neurolues) – late stage of syphilis in which demyelination of the spinal cord occurs]
  • Orthopedic examination [due todifferential diagnoses:
    • Coxarthrosis (osteoarthritis of the hip joint).
    • Behçet’s disease (synonym: Adamantiades-Behçet’s disease; Behçet’s disease; Behçet’s aphthae) – multisystem disease from the rheumatic form circle, which is associated with recurrent, chronic vasculitis (vascular inflammation) of the small and large arteries and mucosal inflammation; The triad (the occurrence of three symptoms) of aphthae (painful, erosive mucosal lesions) in the mouth and aphthous genital ulcers (ulcers in the genital region), as well as uveitis (inflammation of the middle eye skin, which consists of the choroid (choroid), the corpus ciliary (corpus ciliare) and the iris) is stated as typical for the disease; a defect in cellular immunity is suspected
    • Nucleus pulposus prolapse (herniated disc).
    • Sacroiliitis – inflammation of the sacroiliac joint between the sacrum and the ilium]
  • Psychiatric examination [due todifferential diagnosis:
    • Somatoform disorders such as chronic lower abdominal pain syndrome or in severe stress situations]
  • Urological examination [due todifferential diagnoses:
    • Testicular torsion (testicular torsion).
    • Ischuria (urinary retention)
    • Renal infarction
    • Renal colic, mainly caused by kidney stones
    • Perforation of the urinary bladder
    • Pyelonephritis (inflammation of the renal pelvis)
    • Uremia (occurrence of urinary substances in the blood above normal values).
    • Urolithiasis (urinary stone disease)
    • Cystitis (cystitis)]

High-risk clinical variables predictive of the presence of intra-abdominal injury in children:

  • Abdominal tenderness
  • Femur fracture
  • Low systolic blood pressure (age-adjusted values).
  • Laboratory parameters:
    • Initial hematocrit value < 30%.
    • Elevation of transaminases:
      • Aspartate aminotransferase (AST; glutamate oxaloacetate transaminase, GOT) > 200 U/l,
      • Alanine aminotransferase (ALT; glutamate pyruvate transaminase, GPT) > 125 U/l
  • Hematuria > 5 erythrocytes/facial field.

Square brackets [ ] indicate possible pathological (pathological) physical findings.