Post on 29-Jan-2016
Physical Examination
ABDOMEN
RULE #1
POSITION
• The patient should be lying flat on bed• Arms on the sides
exposure
•From the level of nipples to the level of knees.
Don’t forget to :
• Have warm hands and a warm stethoscope.
• Avoid quick, unexpected movements.
• Distract the patient with questions.
• Monitor your examination by watching patient's face.
Abdominal examination
•Abdomen •Back•PR / PV
inspection
1. Contour and symmetry :
Flat abdomen (اذا قابلونيشفتوها (
Inspection
2 .Scars : a. Locationb. Lengthc. Color
Inspection
• 3. skin / dilated veins :
Striae - prolonged stretching of the skin;
seen in ascites, obesity, tumor, pregnancy, and
Cushing's Syndrome
Spider angioma
Inspection• 4. umbilicus: a. Contourb. Locationc. Signs of hernia - lifting head or coughing
Turner’s sign
Inspection• 5. masses / enlarged organs :
hepatomegaly
Inspection
• 6 Peristalsis• 7 . Distribution of Pubic Hair (Escutcheon): a. Female distribution - triangle with base above the symphysis b.Male distribution - diamond with upper vertex extending as high as the umbilicus• 8. respiration pattern : female : thoracoabdominalMale : abdominothoracic
Inspection
• 9. epigasric pulsation : AAA
• https://www.youtube.com/watch?v=CQzjJQmarNk
RULE #2
• If it was your mother lying on the bed , would you do the same thing ?
Auscultation
• You must auscultate before you percuss or palpate abdomen because these maneuvers may alter the frequency of bowel sounds. Enhanced peristaltic sounds may mask other abnormal abdominal sounds such as bruits and friction rubs.
Auscultation
• 1. Bowel sounds - listen and note frequency and character (normal sounds consist of clicks and gurgles and occur 5 to 34 per minute)
. Absence of bowel sound - established only after 5 minutes of continuous listening. Caused by an immobile bowel of adynamic ileus (peritonitis, severe hypokalemia, complete obstruction, paralytic ileus, gangrene). A full bladder can obscure sounds.
Auscultation• 2. Vascular Sounds : Location
Indication
Over abdominal aorta
Atherosclerosis
AneurysmAortic compression by a tumor
Renal arteries
Renal artery stenosis (check for hypertension)
Right upper quadrant
Vascular tumor of the liver (Hepatoma, Hemangioma)
Iliac arteries
Atherosclerosis
Femoral arteries
Atherosclerosis
Auscultation
• Sounds : https://www.youtube.com/watch?v=ZoXbHvFhbi0&list=PL37B77CC6BEDF3DEB
RULE #3
Percussion • Percussion of the abdomen helps assess for intestinal distention,
free fluid, solid masses, hepatomegaly, and splenomegaly.
• It is contraindicated in patients with AAA , organ transplants or injured spleen.
• Percussion for beginners :
•:// . . / ? = 4 5 _4https www youtube com watch v P Ryk IKf
•
Percussion
• Abdominal organs• Liver – percuss up from RIF then down
from right side of chest to determine the size of the liverSpleen – percuss up from RIF moving towards the LUQ to assess for splenomegalyBladder – percuss suprapubic region – differentiating suprapubic masses (bladder (dull) / bowel (resonant))
Percussion
• Shifting dullness
• 1. Percuss from the centre of the abdomen to the flank until dullness is noted2. Keep your finger on the spot at which the percussion note became dull3. Ask patient to roll onto the opposite side to which you have detected the dullness4. Keep the patient on their side for 30 seconds5. Repeat your percussion in the same spot6. If fluid was present (ascites) then the area that was previously dull should now be resonant7. If the flank is now resonant, percuss back to the midline, which if ascites is present, will now be dull (i.e. the dullness has shifted)
Percussion
• Liver : https://www.youtube.com/watch?v=D0G7353qfYw
https://www.youtube.com/watch?v=LmNQGKvTck0
Percussion
• Spleen :https://www.youtube.com/watch?v=hhvGnBUNCgo
. Shifting dullness : https://www.youtube.com/watch?v=b7glKxy7VvI
RULE #4
•BE patient with patients who are not patient .
Palpation
• Remember:• The pads and tips (the most sensitive areas) of the index, middle, and ring fingers
are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures
• Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely to startle the patient or cause discomfort .
• Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel.
• In general, it is easier to detect abnormal if you start in an area that you're sure is normal.
• Ask if the patient has any pain anywhere before you begin!• Look at patients face throughout the examination for signs of discomfort.
Palpation
• 1. Light palpation :• Assess each of the four quadrants for
the following…Tenderness – note the areas involved and the severity of the pain
Rebound tenderness – pain is worsened on releasing the pressure – peritonitis
Guarding – involuntary tension in the abdominal muscles – assess if localized or general
Masses – large / superficial masses may be noted on light palpation
Palpation
• 2 .Deep palpation • Assess each of the four quadrants again,
but with greater pressure on palpation• 1.liver• 2. gallbladder • 3. spleen • 4 .Kidneys• 5 . Aorta• 6 .Bladder
Palpation • Liver• 1. Start palpation in the right iliac fossa• 2. Press your right hand into the abdomen
as you ask the patient to take a deep breath• 3. Feel for a step, as the liver edge passess
below your hand• 4. If you don’t feel anything, repeat the
process with your hand 1-2 cm higher .• If you feel the liver edge, note the
following:• Degree of extension below the costal margin• Consistency of the liver edge
(smooth/irregular)• Tenderness – suggestive of hepatitis • Pulsatility – a pulsatile enlarged liver can be
caused by tricuspid regurgitation
Palpation • Gallbladder• The gallbladder is not usually palpable when healthy
• An enlarged gallbladder suggests obstruction to biliary flow / infection (cholecystitis)
• Perform palpation at the right costal margin, mid-clavicular line (9th rib tip)
• If enlarged, a round mass, moving with respiration may be palpated – note any tenderness
• • Murphys sign:• Place your hand in the area noted above• Ask the patient to take a deep breath• As the gallbladder is pushed down into your hand they may suddenly
develop pain & stop inspiring• This is a positive Murphy’s sign, which is suggestive of cholecystitis
Palpation • Spleen• The spleen is not usually palpable, therefore if
you feel it, it’s at least 3x it’s normal size!
• 1. Start in right iliac fossa – as massive splenomegaly can extend this far!
• 2. Align your fingers in the same direction as the left costal margin
• 3. Press your right hand into the abdomen as you ask the patient to take a deep breath
• 4. Feel for a step, as the splenic edge passess under your hand (a notch may be noted) – note position
• 5. If you don’t feel anything, repeat process with your hand 1-2 cm closer to the LUQ
Palpation
• Kidneys• 1. Place your left hand behind the
patients back at the right flank• 2. Place your right hand just below the
right costal margin in the right flank• 3. Press your right hands fingers deep
into the abdomen• 4. At the same time press upwards
with your left hand• 5. Ask the patient to take a deep
breath• 6. You may feel the lower pole of the
kidney moving inferiorly during inspiration
• 7. Repeat this process on the opposite side to assess the left kidney
Palpation
• Aorta• 1. Palpate using fingers
from both hands• 2. Palpate just above the
umbilicus at the border of the aortic pulsation
• 3. Note the movement of your fingers:
• Upward movement = pulsatile
• Outward movement = expansile (suggestive of AAA
Palpation
• Bladder• An empty bladder will not be
palpable (pelvic)However an enlarged full bladder can be felt arising from behind the pubic symphysisThis may suggest a diagnosis of urinary retention
Palpation
• https://www.youtube.com/watch?v=aSPqXd9PILo
PR/GENETALIA!!!
• Say you would carry out the
following if appropriate…• Check hernial orifices – e.g. if
there’s signs of obstructionPerform a digital recta examination (PR)– e.g. if there’s a suggestion of UGIBPerform an examination of the external genitalia .
Don’t forget to:
1.Thank patient2. Wash hands3. Summarize findings .
DDx
• Think Anatomically: When looking, listening, feeling and percussing imagine what organs live in the area that you are examining. The abdomen is roughly divided into four quadrants: right upper, right lower, left upper and left lower. By thinking in anatomic terms, you will remind yourself of what resides in a particular quadrant and therefore what might be identifiable during both normal and pathologic states
All the best