ABDOMINAL ABDOMINAL EXAMINATIONEXAMINATION

INGUINOSCROTAL INGUINOSCROTAL EXAMINATIONEXAMINATION

DR. HAZEM ZAKARIADR. HAZEM ZAKARIA

Contribution to DiagnosisContribution to Diagnosis

HISTORYEXAMINATIONINVESTIGATION

AppendixCaecumRight OvarySmall bowel

BladderUterusSmall bowel

Sigmoid colonLeft ovarySmall bowel

Descending colonSmall bowelAorta

SpleenColon

StomachDuodenumTr colonAortaPancreas

LiverGallbladderDuodenum

Ascending colon

AortaSmall bowel

ABDOMINAL EXAMINATIONABDOMINAL EXAMINATION COMPLAINT COMPLAINT• Abdominal swellingAbdominal swelling• Abdominal painAbdominal pain• Vomiting, Heart burnVomiting, Heart burn• DyspepsiaDyspepsia• HaematemsisHaematemsis• Bleeding per rectumBleeding per rectum• Bowel habbit changesBowel habbit changes• Abdominal distensionAbdominal distension• Loss of weight,AnorexiaLoss of weight,Anorexia• Easy fatigabilityEasy fatigability• Urinary complaintUrinary complaint• Gynacological symptomsGynacological symptoms

Purpose of examinationPurpose of examination

• To elicit physical signsTo elicit physical signs

• To aid formulation of a diagnosesTo aid formulation of a diagnoses

• To comfort the patientTo comfort the patient

ABDOMINAL ABDOMINAL

EXAMINATION/GENERALEXAMINATION/GENERAL

• General exam begins on first sight of General exam begins on first sight of the patientthe patient

• Examine the whole patientExamine the whole patient

Abdominal Abdominal Examination/GENERALExamination/GENERAL

• General observationGeneral observation– ComfortComfort– PositionPosition– ColourColour– RespirationRespiration

ABDOMINAL ABDOMINAL EXAMINATION/GENERALEXAMINATION/GENERAL

• General examination:General examination:

Mental state: drowsiness,loss of conc.Mental state: drowsiness,loss of conc.

Posture:Leaning forward..Pancreatic lesionPosture:Leaning forward..Pancreatic lesion

Facies: toxic,earthy in uraemia,liver failureFacies: toxic,earthy in uraemia,liver failure

Body built: Underweight, Cachexia,wellBody built: Underweight, Cachexia,well

Vital signs,Head, eyes, Mouth, Neck,Chest, Vital signs,Head, eyes, Mouth, Neck,Chest, U.L,L.L U.L,L.L

Abdominal Abdominal Examination/GENERALExamination/GENERAL

• Head and NeckHead and Neck– EyesEyes

•Colour of scleraColour of sclera•Pallor of eyelidsPallor of eyelids

– TongueTongue•HydrationHydration

– Cervical and supra-clavicular lymph Cervical and supra-clavicular lymph nodesnodes

•Examine from the Examine from the patients right sidepatients right side

ABDOMINAL EXAMINATIONABDOMINAL EXAMINATION

Equipment NeededEquipment NeededA StethoscopeA Stethoscope

General ConsiderationsGeneral ConsiderationsThe patient should have an The patient should have an empty bladderempty bladder . .The patient should be lying supine on the The patient should be lying supine on the exam table and appropriately drapedexam table and appropriately draped . .

The examination room The examination room mustmust be quiet to be quiet to perform adequate auscultation and perform adequate auscultation and percussionpercussion . .

ABDOMINAL EXAMINATIONABDOMINAL EXAMINATION

Starting the examinationStarting the examination..

All examinations start in the same way. All examinations start in the same way. FirstlyFirstly, , the examinee introduces him or herself to the examinee introduces him or herself to the patient, and checks that the patient is the patient, and checks that the patient is comfortable and happy with the procedure. comfortable and happy with the procedure. The patient is then The patient is then positionedpositioned and and exposedexposed. . The examiner should make sure that there is The examiner should make sure that there is the best light available that is possible and the best light available that is possible and that both the patient  and the examiner are that both the patient  and the examiner are comfortablecomfortable..

ABDOMINAL EXAMINATIONABDOMINAL EXAMINATIONWatch the patient's faceWatch the patient's face for signs of discomfort during for signs of discomfort during the examinationthe examination . .Use the appropriate terminology to locate your findingsUse the appropriate terminology to locate your findings::

22 vertical lines,2 transverse lines(subcostal,intertubercularvertical lines,2 transverse lines(subcostal,intertubercular planeplane

Right Upper Quadrant (RUQ)Right Upper Quadrant (RUQ) Right Lower Quadrant (RLQ)Right Lower Quadrant (RLQ) Left Upper Quadrant (LUQ)Left Upper Quadrant (LUQ) Left Lower Quadrant (LLQ)Left Lower Quadrant (LLQ) MidlineMidline : :

EpigastricEpigastric PeriumbilicalPeriumbilical SuprapubicSuprapubic

INSPECTIONINSPECTION

• Expose abdomen from nipple to knee Expose abdomen from nipple to knee

• Stand back: Symmetery Stand back: Symmetery Abdominal movement with respiration Abdominal movement with respiration

• Contour: from the foot of the patientContour: from the foot of the patient

• Subcostal angle: 90-110Subcostal angle: 90-110

widened.. Inc. Intra abdominal pressurewidened.. Inc. Intra abdominal pressure

Rising test: Contraction of Ant. Abd.wall muscle Rising test: Contraction of Ant. Abd.wall muscle

Also by: Carnett’s testAlso by: Carnett’s test

INSPECTIONINSPECTION

• Umbilicus:Umbilicus: site, shape, impulse on cough, site, shape, impulse on cough, discharge,sinusdischarge,sinus Dilated veins:Dilated veins: Caput Medusae,IVC,SVC Caput Medusae,IVC,SVC Pubic hair distributionPubic hair distribution ImpulseImpulse at hernial orifices at hernial orifices Scars Scars of previous operationof previous operation Back :Back : scoliosis,Kyphosis,swelling scoliosis,Kyphosis,swelling Scrotum:Scrotum: mass, skin changes mass, skin changes Swelling :Swelling : site, Intra- or Extra- abdominal (test),size, site, Intra- or Extra- abdominal (test),size, shape,surface,skin shape,surface,skin

overlying,pulsation,impulseoverlying,pulsation,impulse

Abdominal Abdominal Examination/PalpationExamination/Palpation

Clean hands & nailsClean hands & nailsWarm handsWarm handsKneel downKneel downInform patient of your plans -Ask about Inform patient of your plans -Ask about painpainBegin with light palpationBegin with light palpationExamine the quadrants in an anti-Examine the quadrants in an anti-clockwise manner starting so that a clockwise manner starting so that a painful quadrant is lastpainful quadrant is lastUse one hand for palpation & one for Use one hand for palpation & one for positioningpositioning

Abdominal Examination/PalpationAbdominal Examination/Palpation

Avoid guarding of abdominal MusclesAvoid guarding of abdominal Muscles::

Warm handWarm hand

Ask patient to flex his kneesAsk patient to flex his knees

Ask the patient to open his mouth and breathAsk the patient to open his mouth and breath

deeply in &outdeeply in &out

TechniqueTechnique::

Start from region opposite to patient complaintStart from region opposite to patient complaint

& & affected region should be the lastaffected region should be the last

If no complaint: L I fossa,C shape…Last suprapubic If no complaint: L I fossa,C shape…Last suprapubic regionregion

Abdominal Examination/PalpationAbdominal Examination/PalpationMove hand gently and steadily from one Move hand gently and steadily from one quadrant to the nextquadrant to the next

Look at the patients face as you are examiningLook at the patients face as you are examining

Deep palpation – follow the same course as for Deep palpation – follow the same course as for light palpation but with a little firmer light palpation but with a little firmer pressurepressure

If a mass is palpated try to delineate it and If a mass is palpated try to delineate it and note its consistency surface, movements and note its consistency surface, movements and relations to surrounding structuresrelations to surrounding structures

Abdominal Examination/PalpationAbdominal Examination/Palpation

Examine the liverExamine the liver

Begin with the hand low in the abdomen Begin with the hand low in the abdomen ( level of Rt I F.)( level of Rt I F.)

Deeply palpate with the edge of the Deeply palpate with the edge of the examining hand as the patient inspires examining hand as the patient inspires move towards the costal margin with move towards the costal margin with successive inspirationssuccessive inspirations

Four steps should be enoughFour steps should be enough

Percuss the liver to delineate the sizePercuss the liver to delineate the size

Abdominal Examination/PalpationAbdominal Examination/Palpation

• Alternate MethodAlternate Method• This method is useful when the patient is This method is useful when the patient is

obese or when the examiner is small obese or when the examiner is small compared to the patient.compared to the patient.

• Stand by the patient's chest. Stand by the patient's chest. • "Hook" your fingers just below the costal "Hook" your fingers just below the costal

margin and press firmly. margin and press firmly. • Ask the patient to take a deep breath. Ask the patient to take a deep breath. • You may feel the edge of the liver press You may feel the edge of the liver press

against your fingers. against your fingers.

Other methods for liver Other methods for liver palpationpalpation

1-Bimanaual method:1-Bimanaual method: liver edge can be more prominent liver edge can be more prominent

byby

putting Lf. Hand under lower ribsputting Lf. Hand under lower ribs

2-Dipping method :2-Dipping method : in tense ascites in tense ascites

Abdominal Examination/PalpationAbdominal Examination/Palpation

Liver SpanLiver SpanPercuss Percuss downwarddownward from the chest in the from the chest in the right right midclavicular linemidclavicular line until you detect the top edge of until you detect the top edge of liver dullness ,(tidal percussion).. fifth spaceliver dullness ,(tidal percussion).. fifth space..

Percuss Percuss upwardupward from the abdomen in the same line from the abdomen in the same line until you detect the bottom edge of liver dullnessuntil you detect the bottom edge of liver dullness . .

Measure the liver span between these two points. This Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adultmeasurement should be 6-12 cm in a normal adult . .

Abdominal Examination/PalpationAbdominal Examination/Palpation

• Palpation of the AortaPalpation of the Aorta

• Press down deeply in the midline Press down deeply in the midline above the umbilicus. above the umbilicus.

• The aortic pulsation is easily felt on The aortic pulsation is easily felt on most individuals. most individuals.

• A well defined, pulsatile mass, greater A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic than 3 cm across, suggests an aortic aneurysm. aneurysm.

AORTIC ANEURYSMAORTIC ANEURYSM

Abdominal Examination/PalpationAbdominal Examination/Palpation

Examine for the spleenExamine for the spleenNormal:Normal: spleen not palpable (infant,2% in spleen not palpable (infant,2% in adults.. Could palpate with deep adults.. Could palpate with deep inspiration)inspiration)Spleen must enlarge 1.5 time to be palpableSpleen must enlarge 1.5 time to be palpableBegin palpation for spleen in the RIF, move Begin palpation for spleen in the RIF, move toward the LUQ stepwise with inspirationtoward the LUQ stepwise with inspirationSix steps should be enoughSix steps should be enough Recognize the notchRecognize the notchDon’t be surprised if you can’t find itDon’t be surprised if you can’t find it

Abdominal Examination/PalpationAbdominal Examination/Palpation

Splenic DullnessSplenic DullnessPercuss the lowest costal interspace in the Percuss the lowest costal interspace in the left anterior axillary lineleft anterior axillary line. This area is . This area is normally tympaniticnormally tympanitic . .

Ask the patient to take a deep breath and Ask the patient to take a deep breath and percuss this area again. Dullness in this percuss this area again. Dullness in this area is a sign of splenic enlargementarea is a sign of splenic enlargement..

Other methods:Other methods: Bimanual examination Bimanual examination Hooking methodHooking method

Examination of the KidneysExamination of the Kidneys

Normal kidney is not palpableNormal kidney is not palpableIn suspecting renal mass.. Look for renal In suspecting renal mass.. Look for renal angle fullnessangle fullnessBallottement .. Bimanual examinationBallottement .. Bimanual examinationPlace left hand on back below costal margin Place left hand on back below costal margin and palpate with right handand palpate with right handMurphy’s kidney punch.. Tender renal angle Murphy’s kidney punch.. Tender renal angle with thumbwith thumbAgain don’t be surprised if you can’t palpate Again don’t be surprised if you can’t palpate the kidneythe kidney

Examination of abdominal Examination of abdominal massmass

• Site, Intra- or Extra- abdominalSite, Intra- or Extra- abdominal

• Temperature, tendernessTemperature, tenderness

• Size, shape, surface, skin, edgeSize, shape, surface, skin, edge

• Consistency, signs of inflammationConsistency, signs of inflammation

• Pulsation, mobility in 2 directionsPulsation, mobility in 2 directions

PercussionPercussionPercuss in all four quadrants usingPercuss in all four quadrants using proper techniqueproper technique . .

A- Use the wristA- Use the wristB- Use middle finger of Rt hand opposite B- Use middle finger of Rt hand opposite middle phalynx of oppsite middle fingermiddle phalynx of oppsite middle finger

Categorize what you hear as tympanitic Categorize what you hear as tympanitic or dull. Tympany is normally present or dull. Tympany is normally present over most of the abdomen in the supine over most of the abdomen in the supine position. Unusual dullness may be a position. Unusual dullness may be a clue to an underlying abdominal massclue to an underlying abdominal mass..

PERCUSSIONPERCUSSION

• Percuss liver,spleen,kidney (renal angle Percuss liver,spleen,kidney (renal angle normally resonant)normally resonant)

•Ascites :Ascites :• Moderete(1500-3000) :Moderete(1500-3000) : shifting shifting

dullnessdullness

• Minimal( 500-1500) :Minimal( 500-1500) : Percuss Percuss umbilicus in knee elbow positionumbilicus in knee elbow position

• Massive :Massive : Fluid thrill Fluid thrill

Traube’s areaTraube’s area

• Area of tympanic note in lower Lf. Part of Area of tympanic note in lower Lf. Part of the front of the chest(gas of stomach).the front of the chest(gas of stomach).

• Boundaries:Boundaries:LF. :ant. margin of spleenLF. :ant. margin of spleenRT.: inf. Border of liverRT.: inf. Border of liverSuperior: lower border of Lf. LungSuperior: lower border of Lf. LungInf. : Lf. Costal marginInf. : Lf. Costal marginDull in :Dull in : splenomegaly,hepatomegaly,pleural splenomegaly,hepatomegaly,pleural

effusion,huge gastric masseffusion,huge gastric mass

AuscultationAuscultation• Place the diaphragm of your Place the diaphragm of your

stethoscope lightly on the abdomen.stethoscope lightly on the abdomen.

• Listen for bowel soundsListen for bowel sounds. Are they . Are they normal, increased, decreased, or normal, increased, decreased, or absent? absent?

• Listen for bruits over the renal Listen for bruits over the renal arteries, iliac arteries, and aorta. arteries, iliac arteries, and aorta.

• Venous hum:Venous hum: below xyphoid cartilage below xyphoid cartilage in portal hypertension… engorgement in portal hypertension… engorgement of splenic veinof splenic vein

Abdominal soundsAbdominal sounds

• Absent bowel sounds, Absent bowel sounds, ileusileus, is a condition in which , is a condition in which the examiner is unable to hear any bowel sounds the examiner is unable to hear any bowel sounds after listening to each area of the abdomen . after listening to each area of the abdomen .

• Reduced bowel sounds (hypoactive) include a Reduced bowel sounds (hypoactive) include a reduction in the loudness, tone, or regularity of the reduction in the loudness, tone, or regularity of the bowel sounds. Hypoactive bowel sounds are bowel sounds. Hypoactive bowel sounds are normal during sleep, and also occur normally for a normal during sleep, and also occur normally for a short time after the use of certain medications and short time after the use of certain medications and after abdominal surgery.after abdominal surgery.

Abdominal soundsAbdominal sounds

• Increased bowel sounds (hyperactive sounds) are Increased bowel sounds (hyperactive sounds) are sometimes heard even without a stethoscope. sometimes heard even without a stethoscope. They occur at a higher pitch and greater frequency They occur at a higher pitch and greater frequency than normal bowel sounds. than normal bowel sounds. HyperactiveHyperactive bowel bowel sounds reflect an increase in intestinal activity.sounds reflect an increase in intestinal activity.

• The sudden stopping of bowel sounds, or absent The sudden stopping of bowel sounds, or absent bowel sounds after a period of hyperactive bowel bowel sounds after a period of hyperactive bowel sounds, are significant findings that can indicate a sounds, are significant findings that can indicate a potentially life-threatening crisis such as rupture of potentially life-threatening crisis such as rupture of the intestines or strangulation of the bowel the intestines or strangulation of the bowel

Abdominal soundsAbdominal sounds

• Common Causes: Common Causes: HyperactiveHyperactive, hypoactive, or , hypoactive, or absent bowel sounds: absent bowel sounds:

• mechanical mechanical bowel obstructionbowel obstruction (caused by (caused by herniahernia, , tumortumor, , adhesionsadhesions, or similar conditions that can , or similar conditions that can physically block the intestines) physically block the intestines)

• paralytic ileusparalytic ileus, a problem with the nerves to the , a problem with the nerves to the intestines (reduced nerve activity can result from intestines (reduced nerve activity can result from infection, overdistended bowel, trauma, bowel infection, overdistended bowel, trauma, bowel obstruction, vascular obstruction, and chemical obstruction, vascular obstruction, and chemical imbalances such as imbalances such as hypokalemiahypokalemia))

Abdominal soundsAbdominal sounds

• Hyperactive bowel sounds (other Hyperactive bowel sounds (other causes): causes):

• diarrheadiarrhea (any cause including emotional (any cause including emotional stressstress) )

• Crohn’s diseaseCrohn’s disease • GI bleedingGI bleeding • ulcerative colitisulcerative colitis • food allergyfood allergy • infectious infectious enteritisenteritis

Special TestsSpecial Tests

• Rebound TendernessRebound Tenderness

This is a test for peritoneal irritation. This is a test for peritoneal irritation.

Warn the patient what you are about to do. Warn the patient what you are about to do.

Press deeply on the abdomen with your hand. Press deeply on the abdomen with your hand.

After a moment, quickly release pressure. After a moment, quickly release pressure.

If it hurts more when you release, the patient If it hurts more when you release, the patient has rebound tenderness. has rebound tenderness.

Special TestsSpecial Tests • Costovertebral TendernessCostovertebral Tenderness CVA tenderness is often associated CVA tenderness is often associated

with renal disease. with renal disease. Warn the patient what you are about Warn the patient what you are about to do. to do.

Have the patient sit up on the exam Have the patient sit up on the exam table. table.

Use the heel of your closed fist to Use the heel of your closed fist to strike the patient firmly over the strike the patient firmly over the costovertebral angles. costovertebral angles.

Compare the left and right sidesCompare the left and right sides. .

Special TestsSpecial Tests

•Psoas SignPsoas Sign• This is a test for appendicitis. This is a test for appendicitis.

• Place your hand above the patient's Place your hand above the patient's right knee. right knee.

• Ask the patient to flex the right hip Ask the patient to flex the right hip against resistance. against resistance.

• Increased abdominal pain indicates a Increased abdominal pain indicates a positive psoas sign. positive psoas sign.

Special TestsSpecial Tests

•Obturator SignObturator Sign• This is a test for appendicitis. This is a test for appendicitis.

• Raise the patient's right leg with the Raise the patient's right leg with the knee flexed. knee flexed.

• Rotate the leg internally at the hip. Rotate the leg internally at the hip.

• Increased abdominal pain indicates a Increased abdominal pain indicates a positive obturator sign. positive obturator sign.

RECTAL EXAMINATIONRECTAL EXAMINATION

• THE RECTAL EXAMINATIONTHE RECTAL EXAMINATION– Position on left side with knees drawn Position on left side with knees drawn

right up into chestright up into chest– KY on gloveKY on glove– Inspection firstInspection first– Index inserted to full lengthIndex inserted to full length– Comment on tenderness, prostate, Comment on tenderness, prostate,

mass, blood, mucous, faecesmass, blood, mucous, faeces

HERNIAHERNIA

• SwellingSwelling : : increase on cough & decrease in lying down.increase on cough & decrease in lying down. Usually painlessUsually painless• Complication:Complication: irreducibility,obstruction,strangulation irreducibility,obstruction,strangulation• Exam:Exam: standing up, standing up,inspectioninspection:: Inguinal hernia, femoral hernia Inguinal hernia, femoral hernia D.D: Pubic tubercle testD.D: Pubic tubercle test site, size, surface,shape, expansile impulase on cough, scrotum, site, size, surface,shape, expansile impulase on cough, scrotum,

other swellingother swelling

Palpation:Palpation: Temp., tenderness, consistency, gurgling,edge Temp., tenderness, consistency, gurgling,edge D.D scrotal from inguinoscrotal swelling, D.D between direct D.D scrotal from inguinoscrotal swelling, D.D between direct &indirect inguinal hernia (Int. ring test, Ext.ring test)&indirect inguinal hernia (Int. ring test, Ext.ring test)

Auscultation:Auscultation: Intestinal sounds if content is intestine Intestinal sounds if content is intestine

Transillumination :Transillumination : a hydrocele is translucent while hernia is a hydrocele is translucent while hernia is notnot

The scrotumThe scrotum

• C/O :C/O : Pain, swelling, infertility, discharge Pain, swelling, infertility, discharge urinary troublesurinary troubles Inspection:Inspection: Symmetry, size of testis, absent Symmetry, size of testis, absent

testis, swelling , skin (ulcers, sinuses), penistestis, swelling , skin (ulcers, sinuses), penisPalpationPalpation : : a. Spermatic corda. Spermatic cord matted :filariasis, nodules : T.B, cyst: encysted matted :filariasis, nodules : T.B, cyst: encysted

hydrocele .varicocele (bag of warm)hydrocele .varicocele (bag of warm) b. Testis :b. Testis : loss of testicular sensation loss of testicular sensation

(malignancy,Gumma), mass(malignancy,Gumma), mass c. Transilluminationc. Transillumination