14154731 Examination of Abdomen

8/9/2019 14154731 Examination of Abdomen

1/41

GI complaintsGI complaintsCommon signs & symptomsCommon signs & symptoms


2/41

Abdominal PainAbdominal Pain

CommonCommon

What is causing it?What is causing it?

LifeLife--threatening?threatening?


3/41

Acute AbdomenAcute Abdomen

Sudden onset of abdominal painSudden onset of abdominal pain

Indicates peritoneal irritationIndicates peritoneal irritation


4/41

AnatomyAnatomy

Gastrointestinal SystemGastrointestinal System Look it Up!Look it Up!

Renal or Urinary SystemRenal or Urinary System

Reproductive SystemReproductive System

MaleMale FemaleFemale


5/41

The AbdomenThe Abdomen (2 of 2)(2 of 2)


6/41


7/41

Description ofAbdominal PainDescription ofAbdominal Pain

LocalLocal

General ordiffuseGeneral ordiffuse

ReferredReferred

ColicColic


8/41

UlcerUlcer

Erosion of the stomach or intestinal lining.Erosion of the stomach or intestinal lining.

Epigastric or abdominal painEpigastric or abdominal pain HematemesisHematemesis blood in emesisblood in emesis

Bright redBright red

Coffe groundCoffe ground


9/41

HerniaHernia

Protrusion of tissue through body wallProtrusion of tissue through body wall

painpain red orblue skin discolorationred orblue skin discoloration

incarceratedincarcerated

can be serious medical emergencycan be serious medical emergency


10/41

Esophageal VaricesEsophageal Varices

enlargedblood vessels in the esophagusenlargedblood vessels in the esophagus

that can rupturethat can rupture

massive bright redbleeding (oral)massive bright redbleeding (oral)

ShockShock

Hx of liverdisease or ETOH abuseHx of liverdisease or ETOH abuse


11/41

Bowel ObstructionBowel Obstruction

Ablockage of the bowel lumen prohibitingAblockage of the bowel lumen prohibitingthe passage of materialthe passage of material

Hx of recent abdominal surgeryHx of recent abdominal surgery

constipationconstipation

colicky abdominal paincolicky abdominal pain

abdominal distentionabdominal distentionNausea/VomitingNausea/Vomiting


12/41

AppendicitisAppendicitis

Inflammation of the appendixInflammation of the appendix

feverfeveranorexiaanorexia

N/VN/V

RLQ painRLQ pain

Rebound tendernessRebound tenderness


13/41

CholecystitisCholecystitis

Inflammation of the gallbladderInflammation of the gallbladder

Gallstones?Gallstones?recent ingestion of fatty food?recent ingestion of fatty food?

RUQ painRUQ pain

gradual onsetgradual onsetnot colicky painnot colicky pain


14/41

Kidney StonesKidney Stones

Calculi in the kidneyCalculi in the kidney

severe flank painsevere flank painmaybe colickymaybe colicky

restlessnessrestlessness

nausea & vomitingnausea & vomiting


15/41

Urinary Tract Infection (UTI)Urinary Tract Infection (UTI)

Bacterial infection in the urinary tractBacterial infection in the urinary tract

Lower abdominal painLower abdominal painPain and/orburning with urinationPain and/orburning with urination

HematuriaHematuria

Urgency and frequencyUrgency and frequency


16/41

PyelonephritisPyelonephritis

Inflammation of the kidneyInflammation of the kidney

Flank painFlank painPain and/orburning with urinationPain and/orburning with urination

HematuriaHematuria

FeverFever


17/41

Pelvic Inflammatory DiseasePelvic Inflammatory Disease

The inflammation of the female pelvicThe inflammation of the female pelvic

organs (STD)organs (STD)

Dull RLQ or LLQ painDull RLQ or LLQ pain

abnormal vaginal dischargeabnormal vaginal discharge

nausea & vomitingnausea & vomiting

feverfever


18/41

Ectopic PregnancyEctopic Pregnancy

Embryo gestation outside uterus (usuallyEmbryo gestation outside uterus (usually

fallopian tube)fallopian tube)

RLQ or LLQ painRLQ or LLQ pain

late LMPlate LMP

may have vaginal bleedingmay have vaginal bleeding

shockshock


19/41

PeritonitisPeritonitis

Inflammation of the peritoneumInflammation of the peritoneum

Generalized abdominal painGeneralized abdominal painFeverFever

Rigid abdomenRigid abdomen

Nausea and/or vomitingNausea and/or vomitingDistentionDistention


20/41

Dissecting Abdominal AorticDissecting Abdominal Aortic

AneurysmAneurysmAneurysm develops between arterialAneurysm develops between arterial

layerslayers

shearing/tearing abdominal painshearing/tearing abdominal pain

sudden onsetsudden onset

shockshockunequal femoral pulsesunequal femoral pulses


21/41

AssessmentAssessment

OPQRSTOPQRST -- all pain isall pain is notnot the samethe same

SAMPLE or HAMSAMPLE or HAM

nausea, vomiting, diarrheanausea, vomiting, diarrhea

anorexiaanorexia

feverfever weakness or syncopeweakness or syncope


22/41

The physical examThe physical exam

observe fordistentionobserve fordistention

palpate forTRPGRpalpate forTRPGR

check all 4 quadrantscheck all 4 quadrants start away from painstart away from pain


23/41

FemalesFemales

Always consider a gynecological problemAlways consider a gynecological problem

with women having abdominal painwith women having abdominal pain

Pregnant?Pregnant?

LMPLMP

Normal?Normal?

Prior gynecological problemsPrior gynecological problems


24/41

NotesNotes

nasogastric tubes (NG tubes)nasogastric tubes (NG tubes)

gastrointestinal tube (GI tubes)gastrointestinal tube (GI tubes) colostomy / illeostomycolostomy / illeostomy


25/41

GI BleedingGI Bleeding PainPain

heartburnheartburn

Signs of shockSigns of shock

And the following types ofbleedingAnd the following types ofbleeding


26/41

Bright red rectal bleedingBright red rectal bleeding

indicates bleed close to anus.indicates bleed close to anus.

obvious sign ( not subtle )obvious sign ( not subtle ) minorbleeds usually hemorrhoidminorbleeds usually hemorrhoid


27/41

MelenaMelena

Dark, tarDark, tar--like stoolslike stools

Lower GI bleedLower GI bleed

Can be only indication of GI bleedCan be only indication of GI bleed

can represent significant blood losscan represent significant blood loss


28/41

Coffee ground emesisCoffee ground emesis

Partially digestedbloodPartially digestedblood

chronicchronic stomach orduodenumstomach orduodenum


29/41

Bright red emesisBright red emesis

upper Gi bleedupper Gi bleed

above stomachabove stomach

Think Esophageal varicesThink Esophageal varices

Can be severeCan be severe


30/41

HemorrhoidHemorrhoid

Enlargedblood vessels near the anus.Enlargedblood vessels near the anus.

Rectal painRectal pain

bleedingbleeding


31/41

Examination of Abdomen

Position of the patient: the patient should lie flat, with one pillow under the head in

order to relax the muscles of abdominal wall.

Exposure: abdomen shouldbe exposed from xiphisternum to the pubis.

1. Inspection:

Shape of abdomen:

Normally full

Scaphoid: a sunken abdomen due to starvation or wasting disease

Protuberant:due to fat (gross obesity), fetus (pregnancy), flatus (gaseous

distension due to intestinal obstruction), fluid (ascites).Symmetry:

Normally symmetrical

Asymmetry due to visible bulge due to hepatic, splenic and kidney enlargement

or a tumour. Bulging may be central due to uterus, bladder or ovary enlargement.


32/41

Movements:

Normally moving equally with respiration

Respiratory movement of the abdomen usually cease in the presence of acute

peritonitis.

Umbilicus:

normally central and inverted

Placed upwarddue to pregnancy and huge ovarian cyst

Flat or everteddue to ascites.

Prominent veins:Collateral veins visible due to IVC obstruction due to tumour or thrombosis, the

direction of flow is upwards towards heart.

Collateral veins due to cirrhosis radiate from umbilicus forming Caput Medusa,

the direction of flow is downwards towards the leg below the umbilicus.

Skin:

Look for previous surgical scars, striae and pigmentationsStriae may be due to pregnancy, ascites, recent weight loss and Cushings

syndrome.


33/41

Pulsations:

Usually transmitted from the abdominal aorta

Less frequently causedby right ventricle, the liver or an abdominal aneurysm.

Peristalsis:Prominent in small intestinal obstruction

May be visible as slow way of movement passing across the upper abdomen

from left to right in pyloric stenosis

They may be present normally.

Hernias:Look for incisional, epigastric, umbilical, femoral and inguinal hernias.

Inspection of abdomen at eye level:

Squat down beside the bed so that the patients abdomen is at eye level, ask himto take slow anddeep breaths through mouth and watch for any evidence of

asymmetrical movement, indicating the presence of mass such as enlarged liver

and spleen.


34/41

2. Palpation:

General principles:

Ensure that the examining hands are warm.

If patient is in a low bed, sit on, or kneel beside, the bed. Ask the patient if any particular area is tender and examine this area last.

Encourage the patient to breath gently through the mouth.

If necessary, ask the patient to bend the knees to relax the abdominal

muscles.

Palpation can be divided into three phases:1. Light

2. Deep andduring

3. Inspiration

Light palpation:

Object: to note tenderness, guarding, rigidity and lump.

Method:

Place the examining hand on the abdomen and thereafter maintain

continuous contact with the patients abdominal wall.

Note the tenderness and lumps in each region.


35/41

Deep palpation:

Object: to detect deeper masses and to define those already discovered.

Method: palpate the abdomen with the flat of the hand. If a mass is discovered

describe its characteristics such as,

Site, size, tenderness.

Surface which may be regular or irregular.

Edges: regular/irregular

Consistency: hard/soft. Mobility and movement with inspiration.

Pulsatile or not.

Whether one can get above the mass.

Palpation during inspiration:

The liver, spleen, kidney and gall bladder shouldbe examinedduring inspiration.

The key success in visceral palpation is to keep the examining hand still and wait

for the organs edge to descend and strike during inspiration.


36/41

How to palpate liver?

Place the hand flat on the abdomen with the fingers pointing upwards and

position the sensing fingers (middle and index) lateral to the rectus muscle.

Press the hand firmly inward and upward and keep steady while the patient

takes a breath through the mouth.

If the liver edge is palpable describe its character such as sharp or round, hard

or soft, regular or irregular and non-tender or tender.

Causes of tender hepatomegaly are hepatitis, liver abscess andcongestion due

to right heart failure.


37/41

Measuring Liver Span

Percuss from the fourth intercostal space downward and mark

the upperborder of liver identified when percussion note

becomes dull from resonant, usually at the level of sixth rib.

Now percuss from right iliac fossa upwards and mark the level

where the lowerborder of liver is palpable. Measure this spanthat is usually less than 12.5cm. Span increases in

hepatomegaly anddecreases in cirrhosis.

Liver may be palpable without hepatomegaly due to

downwarddescent due to hyperinflation of lung in asthma andCOPD.


38/41

How to measure spleen?

Place the examining hand on the anterior abdominal wall with the fingertips

well below the left costal margin, pressing inwards and upwards.

Ask the patient to take deep breath, if spleen is enlarged it will hit the fingers

during inspiration.

If the spleen is not palpable, the patient must be rolled on the right side

towards the examiner with left hip and knee flexed and palpation is repeatedwith the right hand while the left hand of examiner compressing left lower

costal margin downwards.

If spleen is still not palpable examine the patient from the left side, curling the

fingers of the examining hand under the left costal margin as the patient

breathes in deeply.

Spleen can be palpatedby hooking method while standing on the left side of

the patient.


39/41

How to measure kidney?

Use a bimanual technique to palpate the kidneys.

Place one hand posteriorly below the lower rib cage and the other over the

upper quadrant anteriorly.

Push both hands together firmly and feel the lower pole moving down between

hands as the patient breathes in deeply.

Push kidney back and forwards between the two hands- this is known as

balloting.

Assess the size, surface and consistency of palpable kidney.

Examine the left kidney.


40/41

3. Percussion:

Object:

To differentiate between abdominal distension due to ascites, gas, cystic or

solid tumour. To define the size and nature of organs and masses.

General principles:

Percuss from resonant to dull area.

Percuss the upperborder of liver, and then measure the liver span.

Thrill:

To detect the thrill, place a detecting hand on the patients flank; flick the skin of the

abdominal wall over the other flank using the forefinger.

Shifting dullness:

Percussion shouldbe started in the midline (with the fingers pointing towardsthe feet) then continue percussion towards the flanks until a dull note is

obtained.

Keep the finger in place as the patient rolls to the other side.

Pause for about 10seconds and percuss again.Ascites is suggested if the note

becomes resonant and confirmedby obtaining a dull note while percussing

back towards the umbilicus.


41/41

4.Auscultation:

Place the diaphragm of stethoscopejust below the umbilicus and ascultate for

peristalsis bowel sounds for at least 3 minutes before deciding that they are

absent (i.e. paralytic ileus)

Auscultate liver forbruit present in hepatoma.

Auscultate for renal bruit on either side of midline above the umbilicus, it may

be present in renal artery stenosis.

Auscultate over the aorta forbruit.

**********************************************************************************************

14154731 Examination of Abdomen

Documents

Transcript of 14154731 Examination of Abdomen