- Murphy's sign (a "catch" during inspiration while fingers are hooked under the right costal margin) marginally suggests this

Acute cholecystitis

- a patient with a palpably enlarged gallbladder and jaundice (Courvoisier's sign) has indicators for this

obstruction of the biliary tract (possibly cancer)

- this size of gall stones is the most pathologic

Small stones

- costovertebral angle tenderness (examined by striking with the heel of the hand) is indicative of this

kidney inflammation (polynephritis)

- acute cholecystitis and acute hepatitis reveal tenderness to heel of the hand striking in this region

RUQ and lower ribs

- [normal] gallbladder, pancreas, stomach, small bowel, transverse colon, left kidney, spleen

Non-palpable organs

- size, tenderness, consistency, pulsality

Liver examination

- most clinicians do this to the liver upon examination

underestimate its size

- at the mid-clavicular line, the normal liver size is

9-12 cm

- normal upper border of the liver

7th or 8th rib

- a liver displaced downward is usually found in patients with

emphysema

- fatty infiltration, amyloidosis, neopastic infiltration, cute inflammation, passive venous congestion (RH failure)

Causes of hepatomegaly

- cirrhosis liver size pattern over the course of the disease

normal --> enlarged --> shrunken

- can cause a reduction in liver size (in addition to end-stage cirrhosis)

acute massive hepatocellular necrosis (tissue death)

- this finding on the lower liver edge suggests alcoholic cirrhosis and metastatic cancer

Nodularity

- this physical exam finding can indicate tricuspid regurgitation or constrictive pericarditis (venous backup from RH)

- also can occur with severe tricuspid stenosis

pulsatile liver

- this normal variation of the right lobe of the liver makes it palpable at the right lower costal margin

- should not be confused with hepatomegaly

Riedel's lobe (long tail)

- an palpable spleen argues strongly for this (+LR=9.6)

Splenomegaly

- an enlarged spleen should not be palpated because there is risk of this

- pts with infectious mononucleosis and Ebstein-Barr are at risk for this

Rupture

- at the lowest left intercostal space tympany is usually heard on percussion

- if the sound converts to dullness during deep inspiration, this is most likely present

Mild splenic enlargement

- splenic enlargement occurs towards this region

- downward and to the umbilicus

- a common source of confusion on splenic palpation can be this

stool-filled colon

- a differentiating factor used to discriminate an enlarged spleen from an enlarged kidney on palpation

notch on the medial side of the mass

- because the spleen lies anterior to the splenic flexure and the kidney lies posterior, percussion over a LUQ mass sounds like this for spleen and kidney respectively

dull/tympanic

- splenomegaly with jaundice points to this condition

hepatic disease + portal hypertension

- splenomegaly with pallor can suggest these conditions

leukemia or lymphoma

- splenomegaly with lymphadenopathy suggests these

lymphoma, sarcoidosis, infectious mononucleosis

- normal splenic dullness (10th rib posterior to midaxillary line)

--> tympany to dullness (percuss in lowest interspace in anterior axillary line)

--> palpable on inspiration below left costal margin

--> LLQ w/ notch

--> across midline

Splenic Enlargement

- term used to describe kidney palpation

- two-handed technique where kidney is trapped between hands

ballottement

- this kidney is lower than its counterpart

lower pole of RIGHT kidney

- polycystic kidney disease presents with this symptom

bilaterally enlarged kidneys

- unilaterally enlarged kidney is usually due to this

- can be due to prostate enlargement or kidney stones cause blockage of outflow (enlargement)

hydronephrosis

- stony and hard kidney indicates this

Cancer

- size, location, mobility, consistency, surface texture, tenderness, pulsatility

factors of abdominal masses

- presence of free fluid within the peritoneal cavity

- pt's present with abdominal distention

- in severe cases umbilicus may protrude

Ascites

Cirrhosis + portal hypertension

AND

RH CHF

- male patients w/o this symptom usually do not have ascites

ankle edema

- best test to identify ascites

ultrasound

- this symptom is assessed by percussing laterally and superiorly on the abdomen while they pt lies flat then on their sides

- if the pt's location of resonance to dullness changes, its present

Shifting dullness

- threshhold that is required for shifting dullness to detect ascites

500 cc of free fluid

- shifting dullness is used for its specificity or sensitivity

sensitivity (SNout)

specificity (SPin)

- this condition produces many of the same symptoms as ascites (fluid wave, bulging flanks)

large ovarian cyst

- due to the mass being anterior rather than lateral, an ovarian cyst reveals this percussive sound anteriorly vs laterally (opposite of ascites)

dullness (anterior) vs tympanic (lateral)

- test where the pt extends a straight leg at the hip against resistance applied by examiner

- when it creates pain, there may be retroperitoneal irritation

Iliopsoas sign

- ureteral calculus, retroperitoneal bleed, tuboovarian abscess

causes of retroperitoneal irritation

- performed by having a supine patient flex the thigh to 90 degrees while the examiner rotates the leg internally and externally at the hip

- pelvic pain indicates retroperitoneal irritation

Obturator test

- rectal carcinoma, perirectal abscess, tubo-ovarian abscess, uterine lesions, appendiceal abscess can all be detected with this

Rectal exam

- location of rectovesical pouch during rectal exam

- can contain metastatic deposits with someone who has metastatic intra-abdominal cancer

- revealed by a hard shelf (Blumer's shelf)

anterior and superior to the finger toward the navel

- guaiac testing is associated with this substance sometimes found in the stool

blood