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2014
ABDOMENAL EXAMINATION
ABDOMENAL EXAMINATION
2014
ABDOMENAL EXAMINATION
GENERAL RULES:
Keep the room as warm as possible and make sure that the
lighting is adequate.
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Order of Examination
Inspection
Auscultation
Percussion
Palpation
Inspection
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flanks. 5F
are the causes of abdominal
distentin fat, feces ,flatus ,feotus , fluid.
2.
Abdominal skin --Scars , striae (purple or
silver), dilated veins around umbilicus in caput
medusa veins radiating from the umbilicus & its
direction of flow: from below upward or vise versa
((portal hypertension)) and veins in the lateral
parts
of
abdomen
((
inferior
vena
cava
obstruction))
,rashes and lesions, Peristalsis
(visible--Visible loops of bowel) ,Pulsations (Aorta).
The abdomen is divided into 9 quadrants by two vertical midclavicular
lines and two horizontal linesone through transpylorus and the other
through the anterior iliac spine.
Common scars:
1. Right subcostal scar---- cholycestectomy scar
2. Mid line long lapratomy scar---- acute abdomen of surgical
unknown cause
3. Right or Left lumbar scar---- kidney surgical intervention
4. Suprapubic scar---- Caesarean scar or prostate operation or
pelvic operation.
5. Mid line supra umbilical scarduodenal ulcers , pancreatic
operations.
ABDOMENAL EXAMINATION
3.
2014
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Respiratory movement :
5 DR.MAGDI AWAD SASI
ABDOMENAL EXAMINATION
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Male
--- abdomino-thoracic-respiration.
Female thoraco-abdominal-respiration.
4.
manner
the
of
manner
breathing
of
is
breathing
abdominal
is
thoracic
ABDOMENAL EXAMINATION
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INSPECTION
Shape of the abdomen and flanks
Skin scar
peristalsis
,striae
,prominent
veins
,umbilicus
visible
Size
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Site
Surface
Shape
Affect of cough
Palpation:
Kneel down
Ask about site of abdomenal pain
A. SUPERFICIAL PALPATION:
Aim to get confidence and assurance , to check
temperature ,tenderness.
Palpate the abdomen to detect:
1. Tenderness
Rigidity
2.Muscular rigidity or
3.Superficial organs and
masses
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Start
your
palpation by the
palm of the right
hand from the
right iliac fossa
and go anti-clock
wise .
From
RIF
to
suprapubic left
iliac fossa left lumbar---- left hypochondrial --- epigastric
-----right hypochondrial----right lumbar.. Press down around 1
cm
again flexing at the MCP & IPJ joints. You should still be looking at the patients face for
them flinching due to pain. Again, examine all 9 named segments of the abdomen.
Liver is located under right upper quadant and if the liver enlarged
or pushed it descend toward the right iliac fossa along the mid
calvicular line.
In general, it is easier to detect abnormality if you start in an area
that you're sure is normal by comparison.
The right iliac fossa is the starting point for superficial and deep
palpation.
ABDOMENAL EXAMINATION
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ABDOMENAL EXAMINATION
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Pushing up and in while the
patient takes a deep breath
may make it easier to feel
the liver edge as the
downward movement of the
diaphragm will bring the
liver towards your hand.
The tip of the xyphoid
process, the bony structure
at the bottom end of the
sternum, may be directed
outward or inward and can
be mistaken for an
abdominal mass. You should
be able to distinguish it by
noting its location relative
to the rib cage (i.e. in the
mid-line where the right and
left sides meet).
Lay one hand over the abdomen and push with the second concentrating on the feel of the
bottom hand. Once again, known tender areas should be palpated last.
ABDOMENAL EXAMINATION
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Usual way----1.Start from right iliac fossa with your hand( palm ) parallel to the right costal margin
2.Ask the patient to take deep breath while keeping your hand in touch
3.Ask the patient to exhale , palpate deeply 4 cm in as the abdomen become relaxed
4.Preeced toward the right costal margin through midclavicular line
5. During expiration, palpate deep. During inspiration, moves toward RT costal margin till
you fell the liver margin where you have to ask the patient to take deep breath and go
deeply with your hand 4cm depth. This is because the liver is intraperitoneal and moves
down with inspiration.
For spleen:
The Palpation of the spleen is as for the liver but in the direction of the
left hypochondrium. The edge of the spleen which may be felt if distended is more
nodular than the liver.
The normal spleen in not palpable. When enlarged, it tends to grow towards the
pelvis and the umbilicus (i.e. both down and across)
Another way to assess for splenomegaly is to ask the patient to lie on their right
side.
Support the rib cage with your left hand and again ask the patient to take
deep breaths in moving your right hand up towards the left hypochondrium.
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To feel
for the
kidneys
you
should place one hand under the
patient in the flank region ((right hand
at the inferior and lateral border
of the ribs))and the other hand on top.
---pushing down as you push
Note:
If the liver is palpable , it may be pushed down or enlarged. Liver span is
the next step to be done.
If the spleen is palpable , it is enlarged.
If the liver is palpable , it is important to detect the tenderness--hepatitis or congestion, the size below the costal margin(cm)
13 DR.MAGDI AWAD SASI
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Causes of hepatomegally:
1. Infections--- hepatitis HAV , HBV ,HCV, EBV, CMV , TB abscess , malaria
,alcohol
2. Inflammtion ---- autoimmune hepatitis
3. Ischemia----- bubb chiari syndrome , congested liver ,hepatic vein
thrombosis
4. Tumour ---- hepaoma , lymphoma , leukemia
5. Tumour 2ry--- metastases
6. TB------ abscess
7. Fatty liver
Malaria
Leishmaniasis
CML--- chronic myeloid leukemia
CLL----chronic lymphocytic leukemia
Portal hypertension---- liver cirrhosis is the commonest.
Myelofibrosis
ABDOMENAL EXAMINATION
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Direction of enlargement ----- toward the right iliac fossa toward the midline
Continuity of the dullness on percussion note
Movement with deep breathing as it is intraperitoneal
Splenic notch over the medial site
The examiner cant insert the fingers below the left costal margin
PERCUSSION:
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1.upper border from 2nd
intercostal space through
mid clavicular line, start
percussing on the chest
moving down towards the
abdomen about to 1 cm at
a time. Note where the
percussion notes change
from resonate to dull which
is the beginning of the liver
border((upper)).
For spleen,
As you percuss laterally, note the extent of the tympany; if tympany is prominent
laterally, splenomegaly is unlikely.
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ASCITES
Shifting Dullness
Percuss
centrally
from
the
epigstrium to umbilicus then to
each flank
Locate point of change on side
Ask patient to roll towards you
Wait.for a minute for fluid to move
Percuss again ?area of dullness moved
Fluid Thrill
to other side
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Tuberculosis
GIT tumours--- stomach ,colon , pancrease
Metastases to the peritoneum
Connective tissues diseases
Budd chiari syndrome
Acute pancreatitis
AUSCULTATION:
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SUMMARY PONTS:
1. BOWEL SOUNDS
a. ABSENT
b. LOUD
2. VENOUS HUMS
a. B/W XIPHISTERNUM AND UMBILICUS
3. Renal Bruit
4. Hepatic Bruit
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Succussion Splash
Puddle Sign
Courvoisier's law:
States that in the presence of an enlarged gallbladder which is non tender and
accompanied with mild jaundice, the cause is unlikely to be gallstones. Usually, the term
is used to describe the physical examination finding of the right-upper quadrant of the
abdomen. This sign implicated possible malignancy of the gall bladder or pancreas and
the swelling is unlikely due to gallstones(( because gallstones are formed over an
extended period of time, resulting in a shrunken, fibrotic gall bladder which does not
distend easily)). This shrunken gallbladder is less likely to be palpable on exam. In
contrast, the gallbladder is more often enlarged (and more easily palpated) in pathologies
that cause obstruction of the biliary tree over a shorter period of time such as pancreatic
malignancy leading to passive distention from back pressure. Note that a
palpable tender gallbladder may be seen in acute acalculous cholecystitis, which
commonly follows trauma or ischemia and causes acute inflammation of the gallbladder in
the absence of gallstones.
The exceptions to the law are stones that dislodge and acutely jam the duct distally to the hepatic/cystic duct junction:
ABDOMENAL EXAMINATION
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1.
2.
.The psoas sign: is a medical sign that indicates irritation to the iliopsoas group of hip flexors in
the abdomen, and consequently indicates that the inflamed appendix is retrocaecal in orientation (as
the iliopsoas muscle is retroperitoneal). It is elicited by performing the psoas test by passively
extending the thigh of a patient lying on his side with knees extended, or asking the patient to
actively flex his thigh at the hip. If abdominal pain results, it is a "positive psoas sign". In particular,
the right iliopsoas muscle lies under the appendix when the patient is supine, so a positive psoas
sign on the right may suggest appendicitis. A positive psoas sign may also be present in a patient
with a psoas abscess. It may also be positive with other sources of retroperitoneal irritation, e.g. as
caused by hemorrhage of an iliac vessel.
.Blumberg's sign is a sign that is elicited during physical examination in medicine. It is indicative of peritonitis.
The abdominal wall is compressed slowly and then rapidly released. A positive sign is indicated by presence of
pain upon removal of pressure on the abdominal wall. It is very similar to rebound tenderness
Appendicitis or peritonitis:
Rovsing's sign - pain in the right iliac fossa on palpation of the left side of
the abdomen
Patafio's sign - pain when the patient is asked to cough whilst tensing the
psoas muscle
IF THE PATIENT HAS A HUGE ASCITIS , WHAT IS THE COMMONEST CAUSE AND
WHAT OTHER SIGNS YOU HAVE TO LOOK FOR?
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ABDOMENAL EXAMINATION
The signs that you have to look for are the stigmata of chronic liver
disease.
They are:
Jaundice , spider neavi , Gyanecomastia in male & Breast atrophy in
female , flapping tremors ,palmer erythema , muscle wasting ,
kilonychia ,leuchonychia , ecchymosis , pedal odema.
Those are mandatory to look for in any case of abdominal
examination.
THANKS
ABDOMENAL EXAMINATION