On my previous post on the abdomen, I covered the very important subjects of innies vs. outies and navel lint. This discussion sparked much debate in the scientific community. Well, actually it was read by one person who once took a science class, but that certainly could lead to debate in the scientific community. I try to do my part to advance the cause of science. Now we move on to the rest of the abdominal exam.
As you recall, the physical exam of the abdomen is notated as follows:
Abd: Soft, NT, Normal BS, no HSM or masses.
So lets go through this in order it is written:
Soft is good. At least it is good when you examine the abdomen, although not too soft. When doctors push down on the belly of the patient, the first thing they note is the consistency. If bad stuff is going on in the abdominal cavity, the person involuntarily tenses his/her abdominal muscles. This is known as guarding.
Sometimes guarding is involuntary - the pain is bad enough that people can’t help tensing up. In its extreme - a rigid abdomen - it is tense even when the doctor isn’t pushing down on it. Then there is voluntary guarding, where the patient tenses up on purpose. Why someone would do this is mysterious to me.
Here are some possibilities:
- The doctor’s hands have just come out of a bucket of ice (which I do on a regular basis).
- The patient is trying to get the doctor to order a barium enema.
- The patient wants to get the deductible met faster by having the doctor order a whole lot of tests.
- The patient thinks “voluntary guarding” is a way of serving their country.
To uncover voluntary guarding, the doctor can put the stethoscope on the abdomen and push down. This tricks the patient, and they don’t tense up their abdomen - unless the doctor keeps the stethoscope in a bucket of ice like I do.
The word tender can mean a lot of things:
- To be kind and sympathetic
- To be soft and easy to chew
- To be inclined to roll when blown by the wind
- To offer money as a payment
- A railcar coupled to a steam locomotive to carry fuel and water
- To be sensitive to pain.
Doctors use the last definition (although I sometimes use #3 when examining a boat). In short, if the patient says “Ow, that hurts” when I push on their abdomen, it is tender. Sometimes they just do involuntary guarding instead of saying “Ow, that hurts,” which makes it harder. And that, my friends, is what separates the good doctors from the ones with forged diplomas.
If a patient has a tender abdomen, it can mean they need surgery (appendix, gallbladder), need antibiotics (diverticulitis), or just need to poop. One of my attendings in residency referred to the last one as PID: “Poo in dere.” He told that joke all the time.
When pushing on the abdomen, I often tell a joke of my own. I tell patients that a trick doctors use is to push real hard on the abdomen so that it hurts. Then we can charge more. Pretty clever.
A sign of significant abdominal problems (possibly requiring surgery) is a condition called rebound. Rebound is pain that occurs when the examiner pushes in slowly and then lets go. If the patient has pain when the examiner stops pushing, they have rebound tenderness, which usually means there is serious inflammation in the abdominal cavity which could be life-threatening. If the patient asks the examiner for a date, they are probably just on the rebound.
3. Bowel Sounds
Bowel sounds are not what you think. They are not a noise commonly emanating from a fraternity. Bowel sounds are the gurgling sound a doctor wants to hear when the stethoscope is placed on the abdomen (following the shock from the frigid temperature). It is the sound that similar to the “stomach rumbling” - the trickling of fluid through the intestine. This carries the fun word borborygmi (not to be confused with blogborygmi).
Bowel sounds are evidence of a normally functioning intestinal tract. Sometimes they can become hyperactive - which is when they make a whole bunch of noise (commonly happens at job interviews or blind dates). It generally signifies irritation of the intestines. The intestines are irritated when teased by the spleen. They are also irritated when you get a case of “the trots.”
Diminished or absent bowel sounds are a bigger problem. This happens when the intestines functionally shut down, which can occur with serious conditions like appendicitis and perforated ulcer.
Oregonomegaly is when the state of Oregon invades and annexes Idaho. Organomegaly is when an abdominal organ is enlarged. The two main organs to enlarge are the liver and the spleen. The liver is felt in the right upper part of the abdomen (under the bottom of the ribcage). It is enlarged most commonly from fluid backed up from a poorly-pumping heart. It can also be enlarged from problems from the liver itself. The spleen is on the left side under the ribcage. The significance of the spleen is twofold:
- Trauma can result in a “ruptured spleen,” which is life-threatening.
- Whenever doctors mention the spleen, patients invariably ask: “what does the spleen do?” in response to which the doctor changes the subject.
The spleen is most commonly enlarged with mononucleosis.
Idaho is massing a militia at the border.
When I push on the abdomen, patients often ask me what I am feeling for. “Nothing” is usually my response. I don’t want to feel anything. The “something” I am feeling for (and hoping not to feel) is an abdominal mass. The presence of a mass can signify a tumor (colon or kidney cancer), infection (from prolonged diverticulitis), or an enlargement of the aorta (called an abdominal aortic aneurism - AAA). AAA’s are pulsatile masses that are in the middle of the abdomen. They used to be fixed only with major surgery, but now they can be done in a much less dangerous way (stenting).
I will finish your tour of the abdomen with a story. I was doing a routine exam of a gentleman in his 30’s. As I pushed on his belly, I felt a large smooth mass on his left size. It was really large - about the size of a cantaloupe. “How long have you had this mass?” I asked him.
“What mass?” he responded.
One week later, the surgeon called me with the news. He removed a 7-pound lipoma (benign fatty tumor) from the gentleman’s abdomen. The patient named it Susan.
Have a cigar.