MEDICINE

The Abdomen IAPP - Dr. Tolentino

11/28/12

11/28/12 INSPECTION Is often slighted since physicians have an obsessive desire to place hands on abdomen A. CONTOUR OF THE ABDOMEN Imaginary line from the xiphoid process to the symphysis pubis Flat, Scaphoid, Protruberant 8 Fs of abdominal distention o Fat o Fluid o Flatus o Fetus o Food o Feces o Foreign body (parasites) o Fatal growths (tumors) Pseudocyesis o phantom cause of abdominal distention SYMMETRY or ASYMMETRY Asymmetry due to enlarged mass or organ (i.e. Fetus, mass) Bulging flanks of the ascites Suprapubic bulge of the distended bladder SKIN Color o Hypopigmentation o Hyperpigmentation o Cyanosis o Tinea versicolor : white or brown Fungal cause: Molasia furfur? Dehydration s/sx Scars o Traumatic o Surgical marks Measure and location Striae o New (pinkish or bluish) o Old (silvery) o Pregnancy, obese, ascites Rashes o Dengue o Measles o Rose spots due to typhoid fever Linea nigra o Pregnancy Skin lesions o Contact dermatitis Periumbilical area with signs of excoriation Belt buckles, buttons o Tinea versicolor o Scabies or body lice Inspect even the interdigital areas, inguinal areas Intertriginous areas Engorged or dilated veins o Indicative obstruction either the portal vein or the inferior vein cava o Caput medusa

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UMBILICUS Inverted Flat Everted o Hernia o Increased intra-abdominal pressure Fluid Ascites Discoloration around CULLENs sign o Bluish umbilicus die to hemoperitoneum from any cause such as acute pancreatitis GREY-TURNERs sign o Blue red; blue-purple or green brown discoloration of the skin of the lower abdominal abdomen or flanks Nodules May be the only sign of metastasizing intraabdominal malignancy o SISTER MARY JOSEPH NODULES Everted umbilicus without hernia Due to increased intra-abdominal pressure Umbilical fistula Note for urine or pus from a patent URACHUS Umbilical calculus Not a true stone Hard mass of dirt that accumulate in the umbilical cavity Seen in poor hygiene Visible peristalsis Visible pulsations Normal aortic pulsation is frequently visible in the epigastrium o Watch out for AAA Diastasis recti Abdominal separation of the abdominal rectus muscles o Pregnancy Test: valsalva maneuver

MEDICINE

The Abdomen IAPP - Dr. Tolentino

11/28/12

120712 Palpation Percussion Done by tapping the abdomen Helps to assess the amount and distribution of gas in the abdomen and to identify possible masses that are solid or fluid filled Sounds depend on the structure underlying the area Percuss lightly in all quadrants to asses the distribution of tympany and dullness Normally, percussion over the abdomen produces a hollow sound because ofair within the GI tract o Lungs, resonant? GI, tympany? Maneuvers to check for the presence of fluid in the abdomen o Fluid wave o Shifting dullness o Puddle sign Fluid wave Pathogneumonic of fluid in the abdomen Free fluid Fingers at wall hand, tap sharply at the lateral wall with the other hand Theis produces a wave transmitted to the hand of the other side of the abdomen and felt as a bump How to differentiate fluid wave from fat wave? o Fat wave, receiving fingers cannot receive a bump even with an obstruction at the middle of the abdomen o Flud wave, even with obstruction, there is a wave felt Shifting dullness On supine position: free fluid in the abdomen gravitates to the flanks and the intestines float upwards o Onleft lateral, the lower side will be dull and the upper side will become tympanitic On percussion, tympanitic over anterior abdomen and dull over the flanks What if there is only 30ml or 100ml of fluid? o This is undetected by the shifting dullness o How do you detect it then? Puddle sign May indicate the presence of as little as 120 ml of free fluid in the peritoneal space When the edge of the puddle is passed, the sound becomes accentuated and you will note a point of demarcation that correlated well with the amount of fluid present When the patient sits up, the difference in sound transmission disappears Scratch method: note the lower border of the LIVER Massive ascites Cannot palpate the liver Chest piece of stet may be stationary or move from lower quadrant going to upper border Scratch the side Note for accentuation in the sound Hypogastric to liver, LLQ to liver

LIVER: percussion Superior border: MCL and MSL 4-8 cm in MSL 6-12 cm in Right MCL Hepatomegaly even when there is not hepatomegaly: 1. Hyperinflation of the lungs pushes the diaphragm and liver donw 2. Thin individual 3. Tumor below the diaphragm 4. Ptosis of the liver 5. Abscesses or tumor on the superior border of the liver Always give the liver span Spleen: percussion 1. Percuss the left lower anterior chest Traubes space bwtween lung resonance Splenic dullness at 9th 11th ICS in the AAL 2. Splenic percussion sign Lowest ICS in the Left AAL Area is tympanitic Deep breath percuss again Spleen size is normal, percussion note is usually remains tympanitic (+): change in percussion note from tympany to dullness suggest splenic enlargement Middle tones sign Murphys sign Hepatitis Cholecystitis Deep breath Rovsings sign Rebound pain to right from deep palpation at left Heel Jarring method Patient at prone palpate Psoas sign pain elicited by extending the hip with the knee at full extension Obturator sign OVARIAN CYST Must be distinguished from ascites May fill up much of the abdominal cavity Free fluid or encysted fluid? o Can we use fluid wave? Shifting dullness? Puddle sign? 3 signs: o Curve more pronounced at lower half o Gas filled intestines, producing tympany, fill the superior half of the cavity instead of floating at the top o RULER test When the ruler is pressed transversely across the abdomen with free fluid, the pulsation of the abdominal aorta is not transmitted If the fluid is enclosed in a tight cyst, the aortic pulsation will move the ruler o Distribution of dullness with ovarian cyst

Size of mass Scar Fundic height (pregnant uterus) 1. 2. 3. Explain procedure Drape patient Expose areas

Measurements: Abdominal girth Liver span