Pemeriksaan Abdomen

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Transcript of Pemeriksaan Abdomen

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PEMERIKSAAN ABDOMEN

KKD

UNPAR

Sabtu 8 April 2023

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PEMERIKSAAN ABDOMEN

Anamnesis

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The History and Physical in The History and Physical in PerspectivePerspective

70%70% of diagnoses can be made based on of diagnoses can be made based on historyhistory alone. alone. 90%90% of diagnoses can be made based on of diagnoses can be made based on history and physical examhistory and physical exam. . Expensive testsExpensive tests often confirm what is often confirm what is found during the found during the history and physicalhistory and physical. .

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HISTORY QUESTIONSHISTORY QUESTIONS

PAIN IN ABDOMENPAIN IN ABDOMEN

CHANGE IN APPETITECHANGE IN APPETITE

CHEWING AND SWALLOWING CHEWING AND SWALLOWING PROBLEMSPROBLEMS

HEARTBURNHEARTBURN

NAUSEA, VOMITING, REGURITATIONNAUSEA, VOMITING, REGURITATION

RECTAL BLEEDINGRECTAL BLEEDING

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HISTORY QUESTIONSHISTORY QUESTIONS

ELIMINATIONELIMINATION

HEMORRHOIDSHEMORRHOIDS

VOIDING DIFFICULTYVOIDING DIFFICULTY

PREVIOUS SURGERYPREVIOUS SURGERY

WEIGHT GAIN OR LOSSWEIGHT GAIN OR LOSS

TYPE OF DIETTYPE OF DIET

MEDICATIONS MEDICATIONS

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DysphagiaDysphagia

Signs and symptomsSigns and symptoms– Reports of difficulty swallowingReports of difficulty swallowing– Difficulty controlling food or saliva in Difficulty controlling food or saliva in

mouthmouth– Facial droopFacial droop– Dementia, frailty, confusionDementia, frailty, confusion– Inability to sit uprightInability to sit upright

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Gastroesophageal Reflux Gastroesophageal Reflux DiseaseDisease

Signs and symptomsSigns and symptoms– HeartburnHeartburn– IndigestionIndigestion– Belching:Belching:((also known as also known as burpingburping, , ructusructus, or , or eructationeructation) )

involves the release of involves the release of gas from the digestive tract (mainly from the digestive tract (mainly esophagus and and stomach) through the ) through the mouth..

– HiccupsHiccups– Regurgitation of gastric contentsRegurgitation of gastric contents– Voice hoarseness Voice hoarseness

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Liver and Biliary DisordersLiver and Biliary Disorders

Signs and symptomsSigns and symptoms– Older adults often present with vague, Older adults often present with vague,

ambiguous symptomsambiguous symptoms– Fatigue Fatigue – Weight lossWeight loss– AnorexiaAnorexia– MalaiseMalaise

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PEMERIKSAAN ABDOMENPEMERIKSAAN ABDOMEN

Think Think AnatomicallyAnatomically

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Think AnatomicallyThink Anatomically

When looking, When looking, listening, feeling and listening, feeling and percussing percussing imagine imagine what organs livewhat organs live in in the area that you are the area that you are examining. examining.

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Quadrants & Regions of the abdomen

MSP: mid-sagittal planeMSP: mid-sagittal planeTUP: transumblical plane (L4/5)TUP: transumblical plane (L4/5)

RLL: right lateral planeRLL: right lateral planeLLL : left lateral planeLLL : left lateral planeTPP: transpyloric plane (L 1)TPP: transpyloric plane (L 1)TTP: transtubercular plane (L 5)TTP: transtubercular plane (L 5)

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Regions of the abdomen

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Right Upper Quadrant (RUQ)Right Upper Quadrant (RUQ)

liver, liver, gallbladdergallbladder, , duodenum, duodenum, right kidney right kidney and hepatic and hepatic flexure of colonflexure of colon

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Right Lower Quadrant (RLQ)Right Lower Quadrant (RLQ)

Cecum, Cecum, appendix (in appendix (in case of female, case of female, right ovary & right ovary & tube)tube)

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Left Lower Quadrant (LLQ)Left Lower Quadrant (LLQ)

Sigmoid Sigmoid colon (in case colon (in case of female, left of female, left ovary & tube)ovary & tube)

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Left Upper Quadrant (LUQ)Left Upper Quadrant (LUQ)

Stomach, Stomach, spleen, left spleen, left kidney, pancreas kidney, pancreas (tail), splenic (tail), splenic flexure of colonflexure of colon

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Epigastric AreaEpigastric Area

Stomach, Stomach, pancreas pancreas (head and (head and body), aortabody), aorta

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Landmarks of the abdominal wall,

Costal margin, umbilicus, iliac crest, anterior superior iliac spine, symphysis pubis, pubic tubercle, inguinal ligament, rectus abdominis muscle, xiphoid process.

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Physical Examination of the Physical Examination of the AbdomenAbdomen

InspectionInspection   Auscultation   Auscultation   Percussion   Percussion   Palpation   Palpation   Special Tests    Special Tests

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1. The patient should have an empty bladder. 2. The patient should be lying supine on the exam table and

appropriately draped. 3. The examination room must be quiet to perform adequate

auscultation and percussion. 4. Watch the patient's face for signs of discomfort during the

examination.5. Use the appropriate terminology to locate your findings 6. Disorders in the chest will often manifest with abdominal symptoms.

It is always wise to examine the chest when evaluating an abdominal complaint.

7. Consider the inguinal/rectal examination in males. Consider the pelvic/rectal examination in females.

EXAM SECTIONS1. Inspection 2. Auscultation 3. Percussion 4. Palpation

General Considerations

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Physicians locate findings in the abdomen in one of four quadrants or one of nine regions.

The four quadrants are: • right upper (RUQ), • right lower (RLQ), • left upper (LUQ) and • left lower (LLQ).

THE NINE REGIONS • epigastric, • umbilical, • hypogastric/suprapubic, • right hypochondriac, • left hypochondriac, • right lumbar, • left lumbar, • right inguinal and • left inguinal.

1. INSPECTION

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• HAIR DISTRIBUTION• UMBILICUS• CONTOURo a. FLATo b. ROUNDEDo c. SCAPHOIDo d. PROTUBERANT

(DISTENDED)• PERISTALSIS

1. INSPECTION

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LOCATIONS of ABDOMINAL ORGANS

The schematic below is a reminder of what organs are likely to produce findings in each region. For example:

– Right hypochondriac (RUQ) : liver and gall bladder

– left hypochondriac (LUQ) : the spleen and stomach

– epigastric : the pancreas, stomach and common bile duct

– umbilical : the small intestine – lumbar : the kidneys – iliac regions : the ovaries – left iliac/LLQ : the sigmoid colon – right iliac or lumbar (RLQ): the cecum and

appendix – suprapubic : the bladder and uterus

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SOME COMMON FINDINGS on ABDOMINAL INSPECTION

– Scars : Jaringan parut– Striae (stretch marks) : tanda peregangan ibu

hamil– Colors : - Bluish color at the umbilicus is Cullen's sign – a sign

of bleeding in the peritoneum. - Bruises on the flanks are Grey Turner's sign

(retroperitoneal bleeding - e.g. from inflamed pancreas)

– Jaundice : warna kuning pada kulit– Prominent veins : may be due to portal vein

obstruction or inferior vena cava obstruction

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ABDOMINAL DISTENSION

Distension of the lower abdomen only can be caused by pregnancy, full bladder, ovarian tumor, or uterine fibroids (common benign growths) Diffuse abdominal distension can be caused by any of the 6 Fs:

– Fat (obesity) – Fluid (ascites - peritoneal fluid - or obstructed viscera

filled with fluid) – Flatus (air) - e.g. from air swallowing or intestinal

obstruction – Feces (constipation – Fetus (pregnancy) – Fatal cancer.

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Appearance of the abdomenAppearance of the abdomen

Is Aortic Is Aortic pulsationpulsation? ?

Is it flat or Is it flat or Scaphoid Scaphoid ((Normally)?Normally)?

DistendedDistended? ?

If enlarged, does this If enlarged, does this appear appear symmetricsymmetric??

With With bulging or bulging or movingmoving??

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Symmetrical in shapeSymmetrical in shape

Scaphoid or flat in young patients of normal weight

slightly full but not distended in older age group due to poor muscle tone or in subjects who are mildly overweight

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Appreciation of abdominal contoursAppreciation of abdominal contours

Standing at the footStanding at the foot of of the table and looking up the table and looking up towards the patient's towards the patient's head. head. Lower yourself until the Lower yourself until the anterior abdominal anterior abdominal wallwall and ask the patient and ask the patient to breathe normally while to breathe normally while you are doing so. you are doing so.

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Appearance of the abdomenAppearance of the abdomen

Global Global abdominal abdominal enlargement is enlargement is usually caused usually caused by by airair, , fluidfluid, or , or fatfat..

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Appearance of the abdomenAppearance of the abdomen

Localized Localized enlargement enlargement probably distend probably distend GB space GB space occupyingoccupying lesion, lesion, hepatomegaly….hepatomegaly….

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An aortic aneurysmAn aortic aneurysm

Palpable massPalpable mass

Patient feeling of Patient feeling of pulsationpulsation

On rare occasions, a On rare occasions, a lump can be visible. lump can be visible.

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An aortic aneurysmAn aortic aneurysm

1 in 10 men1 in 10 men over 65 over 65 may have some may have some enlargement of the enlargement of the abdominal aorta. abdominal aorta. About About 1 in 1001 in 100 will will have a have a large large aneurysmaneurysm requiring requiring surgery. surgery.

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Appearance of the abdomenAppearance of the abdomen((Skin)Skin)

Abnormal Abnormal venousvenous patternspatterns

Abnormal Abnormal discolorationdiscoloration

Umbilicus isUmbilicus is sunkensunken

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StriaeStriae

Stretch marks are a Stretch marks are a light silver hue.light silver hue.

Pregnancy and obese Pregnancy and obese individualsindividuals

Cushing’s syndrome Cushing’s syndrome (more purple or pink).(more purple or pink).

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Appearance of the abdomenAppearance of the abdomen ( (Skin)Skin)

TattoosTattoosScars can be drawn on schematic diagrams of the abdomen (a picture is worth a thousand words).

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Cullen’s signCullen’s sign

Ecchymosis Ecchymosis periumbilicallyperiumbilically. . (intraperitoneal (intraperitoneal hemorrhage hemorrhage ruptured ectopic ruptured ectopic pregnancy, pregnancy, hemorrhagic hemorrhagic pancreatitis..)pancreatitis..)

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Grey-Turner’s signGrey-Turner’s sign

Ecchymosis of Ecchymosis of flanks. flanks. ((retroperitoneal retroperitoneal hemorrhage hemorrhage such as such as hemorrhagic hemorrhagic pancreatitis) pancreatitis)

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Upward flow direction indicates IVC obstruction

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Outward flow pattern from umbilicus in all directions ? Portal HTN

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Evaluate venous return states

Place index finger side by side over a vein and press laterally, milking vein.

Release one finger and time refill, repeat with other finger. Venous return is in direction of faster filling.

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Appearance of the abdomenAppearance of the abdomen

Areas which Areas which become more become more pronounced when pronounced when the patient the patient valsalvasvalsalvas are are often associated often associated with with ventral ventral herniashernias

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Visible PulsationsVisible Pulsations

More conspicuous in the More conspicuous in the thin than in the fatthin than in the fat

Greater in the old than in Greater in the old than in the young.the young.

Increased in Increased in thyrotoxicosis, thyrotoxicosis, hypertension, or aortic hypertension, or aortic regurgitation)regurgitation)

In those with an aortic In those with an aortic aneurysm and tortuous aneurysm and tortuous aortaaorta

In those who have a In those who have a mass joining the aorta to mass joining the aorta to the anterior abdominal the anterior abdominal wall. wall.

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Visible gastric PeristalsisVisible gastric Peristalsis

Gastric peristalsis is Gastric peristalsis is commonly seen in commonly seen in neonates with neonates with congenital congenital hypertrophic pyloric hypertrophic pyloric stenosisstenosis

Intestinal peristalsis in Intestinal peristalsis in partial and chronic partial and chronic intestinal obstructionintestinal obstruction

Colonic obstruction is Colonic obstruction is usually not manifest usually not manifest as visible peristalsis as visible peristalsis

Visible intestinal Visible intestinal PeristalsisPeristalsis

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Appearance of the abdomenAppearance of the abdomen Patient's movement Patient's movement

Patients with Patients with kidney kidney stonesstones will frequently will frequently writhe on the writhe on the examination table, examination table,

unableunable to find a to find a

comfortablecomfortable positionposition

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Appearance of the abdomenAppearance of the abdomen Patient's movement Patient's movement

Patients with Patients with peritonitisperitonitis prefer to lie prefer to lie

very stillvery still as any as any motion causes further motion causes further peritoneal irritation peritoneal irritation and pain. and pain.

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2. AUSCULTATION

GUT SOUNDS

• Use the diaphragm of your stethoscope to listen to gut sounds • Normal gut sounds are   gurgling, 5 to 35 per minute • Borborygmi are loud, easily audible sounds. They are normal, too. • High pitched , tinkling (raindrops in a barrel) sounds are a sign of

early intestinal obstruction • Decreased sounds: (none for a minute) are a sign of decreased

gut activity. Gut sounds may be markedly decreased after abdominal surgery; abdominal infection (peritonitis) or injury.

• Absent Sounds :   (no sounds for 5 minutes) are a bad sign. They can be caused by longer-lasting intestinal obstruction, intestinal perforation or intestinal (mesenteric) ischemia or infarction

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2. AUSCULTATION

• Active bowel sounds 5-30/min

• Hypoactive 4/min or less

• Hyperactive 30 or more /min

• Bruitso A. Aortao B. Renalo C. Iliac

• Friction rub

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Auscultation for bowel soundsAuscultation for bowel sounds

It is performed It is performed before before percussion or percussion or palpationpalpation

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Auscultation for bowel soundsAuscultation for bowel sounds

Normal sounds are Normal sounds are

due to due to peristaltic peristaltic activityactivity..Peristalsis: A Peristalsis: A pregressice pregressice wavelike wavelike movementmovement that occurs that occurs involuntarily in hollow involuntarily in hollow tubes of the body. tubes of the body.

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Auscultation for bowel soundsAuscultation for bowel sounds

Compared to the Compared to the cardiac and cardiac and pulmonary examspulmonary exams, , auscultation of the auscultation of the abdomen has a abdomen has a relatively minor role. relatively minor role.

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Auscultation for bowel soundsAuscultation for bowel sounds

Bowel sounds lend Bowel sounds lend supporting supporting information to other information to other findings but are not findings but are not

pathognomonicpathognomonic for any particular for any particular process. process.

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AuscultationAuscultation

1.1.Diaphragm Diaphragm of of stethoscope stethoscope usedused

2.Skin 2.Skin depressed to depressed to approximately approximately 1 1 cm cm

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AuscultationAuscultation

3.Listening in 3.Listening in one one spotspot is usually is usually sufficientsufficient

4.Listening for 4.Listening for 15-20 15-20 or 30-60or 30-60 seconds seconds5.Bowel sounds 5.Bowel sounds cannot cannot be said to be absentbe said to be absent unless they are not heard unless they are not heard after listening for after listening for 3-5 3-5 minutesminutes. .

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Three things about bowel Three things about bowel soundsound

Are bowel sounds Are bowel sounds present?present?

If present, are they If present, are they frequent or sparse frequent or sparse (i.e.quantity)? (i.e.quantity)?

What is the nature of What is the nature of the sounds the sounds (i.e.quality)? (i.e.quality)?

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Bowel sound decreaseBowel sound decrease

Inflammatory Inflammatory processesprocesses of the of the serosaserosa

After abdominal After abdominal surgery surgery

In response to narcotic In response to narcotic analgesics or analgesics or anesthesia. anesthesia.

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Auscultation for bowel soundsAuscultation for bowel sounds

Inflammation of the Inflammation of the intestinal mucosaintestinal mucosa will cause will cause hyperactivehyperactive bowel bowel sounds. sounds.

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Auscultation for bowel soundsAuscultation for bowel sounds

Processes which Processes which lead to lead to intestinal intestinal obstructionobstruction initially initially cause frequent cause frequent bowel sounds, bowel sounds, referred to as referred to as "rushes.""rushes."

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Auscultation for bowel Auscultation for bowel soundssounds

Processes which lead Processes which lead to intestinal to intestinal obstruction initially obstruction initially cause frequent bowel cause frequent bowel sounds, referred to as sounds, referred to as "rushes.""rushes."

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Auscultation for bowel soundsAuscultation for bowel sounds

““Rushes" means Rushes" means as the intestines as the intestines trying to trying to force force their contentstheir contents through a through a tight tight opening.opening.

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Auscultation for bowel Auscultation for bowel soundssounds

““Rushes" is followed Rushes" is followed by by decreased sounddecreased sound, , called "called "tinklestinkles," and ," and then silence. then silence.

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Auscultation for bowel Auscultation for bowel soundssounds

After After silence silence the the appearance of bowel appearance of bowel sounds marks the sounds marks the return of intestinal return of intestinal soundssounds activity, an activity, an important phase of important phase of the patient's the patient's recoveryrecovery. .

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Splash SignSplash Sign

Splashing sound Splashing sound indicative of indicative of air or air or fluid in body cavity fluid in body cavity with shaking with shaking individualindividual: normal in s : normal in s stomach. stomach.

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Auscultation for bowel soundsAuscultation for bowel sounds

Bowel sounds, Bowel sounds, then, must be then, must be interpreted interpreted within within the context of the the context of the particular clinical particular clinical situationsituation. .

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BruitsBruits

Bruits Bruits confined confined to systoleto systole do not do not necessarily necessarily indicate diseaseindicate disease. .

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Auscultation for vascular sounds Auscultation for vascular sounds (bruits)(bruits)

AorticAortic (midline between (midline between umbilicus and xiphoidumbilicus and xiphoid

RenalRenal ( (two inches two inches superiorsuperior to and to and two two inches lateral toinches lateral to umbilicus)umbilicus)

Common iliac (Common iliac (midway midway between umbilicus between umbilicus and midpoint of and midpoint of inguinal ligamentinguinal ligament))

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Auscultation for vascular sounds Auscultation for vascular sounds (bruits)(bruits)

Presence of a Presence of a bruit bruit on the renal arteryon the renal artery would lend would lend supporting supporting evidence for the evidence for the existence of existence of renal renal artery stenosisartery stenosis. .

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Auscultation for vascular soundsAuscultation for vascular sounds(bruits)(bruits)

When listening for When listening for bruits, you will need bruits, you will need to to press down quite press down quite firmlyfirmly as the as the renal renal arteriesarteries are are retroperitonealretroperitoneal structures. structures.

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Venous Hum (rare)Venous Hum (rare)

Epigastric/umbilical Epigastric/umbilical areaarea. .

Soft hummingSoft humming noises noises in in systolic/diastolicsystolic/diastolic component. component.

Indicates Indicates collateral collateral between portal and between portal and venous systemsvenous systems as in as in hepatic cirrhosis. hepatic cirrhosis.

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Rubs –Rubs-RubsRubs –Rubs-Rubs

Liver Liver

SpleenSpleen

CardiacCardiac

Pulmonary Pulmonary

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Friction rubs (rare)Friction rubs (rare)

Right and leftRight and left upper upper quandrants quandrants Grating sound with Grating sound with respiratory movementrespiratory movement Indicates Indicates inflammation of the inflammation of the capsule of the liver or capsule of the liver or spleen (spleen (infection or infection or infarctioninfarction). ).

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3. PERCUSSION

What it finds: liver size (kind of), spleen, fluid. Percussing the body gives one of three notes: • Tympany is found in most of the abdomen,

caused by air in the gut. It has a   higher pitch than the lung.

• Resonance is found in normal lung. It is lower pitched and hollow.

• Dullness is a flat sound, without echoes. The liver and spleen, and fluid in the peritoneum (ascites: ah-SY-teez), give a dull note.

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A. Liver Span• Percuss downward from the chest in the right midclavicular line

until you detect the top edge of liver dullness. • Percuss upward from the abdomen in the same line until you detect

the bottom edge of liver dullness. • Measure the liver span between these two points. This

measurement should be 6-12 cm in a normal adult.

B. Splenic Dullness• Percuss the lowest costal interspace in the left anterior axillary

line. This area is normally tympanitic. • Ask the patient to take a deep breath and percuss this area again.

Dullness in this area is a sign of splenic enlargement.

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PercussionPercussion

Technique Technique

Liver Liver

SpleenSpleen

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Percussion (technique)Percussion (technique)

DIP joint of third DIP joint of third fingerfinger (pleximeter) (pleximeter) pressed firmly on the pressed firmly on the abdomen abdomen remainder remainder of hand not touching of hand not touching the abdomenthe abdomen

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Percussion (technique)Percussion (technique)

Striking hand Striking hand should move should move only at the only at the wristwrist, , with only little with only little more than more than force force of gravityof gravity

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Percussion (technique)Percussion (technique)

Middle fingerMiddle finger of of striking hand striking hand (plexor) should (plexor) should knock the knock the pleximeter firmly, pleximeter firmly, with a with a strong strong notenote

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There are two basic sounds with There are two basic sounds with PercussionPercussion

TympaniticTympanitic (drum-like) (drum-like) sounds sounds produced by produced by percussing over percussing over air filled air filled structuresstructures. .

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There are two basic sounds with There are two basic sounds with PercussionPercussion

Dull soundsDull sounds that that occur when a occur when a solid solid structurestructure (e.g. liver) (e.g. liver) or or fluid fluid (e.g. ascites) (e.g. ascites) lies beneath the lies beneath the region being region being examined. examined.

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Examination of Liver (Percussion)Examination of Liver (Percussion)

MidclavicularMidclavicular line line is notedis noted

Second Second intercostalintercostal space space is notedis noted

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The two solid organs are percussable in the normal patientLiver: will be entirely covered by the ribs. Occasionally, an edge may protrude 1-2 centimeter below the costal margin.

Spleen: The spleen is smaller and is entirely protected by the ribs.

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To determine the size of the liverTo determine the size of the liver

Measure the liver Measure the liver span by percussing span by percussing hepatic dullness from hepatic dullness from above (lung) and above (lung) and below (bowel).below (bowel). A A normal liver span is normal liver span is 6 6 to 12 cmto 12 cm in the in the midclavicular line.midclavicular line.

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To determine the size of the liverTo determine the size of the liver

Start just below the Start just below the right breastright breast in a line in a line with the middle of with the middle of the clavicle. the clavicle. Percussion in this Percussion in this area should area should produce a relatively produce a relatively resonant note. resonant note.

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To determine the size of the liverTo determine the size of the liver

Move your hand Move your hand down a few down a few centimeters than centimeters than you will be over you will be over the liver, which the liver, which will produce a will produce a duller sounding duller sounding tone. tone.

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To determine the size of the liverTo determine the size of the liver

Continue Continue downwarddownward until until the sound the sound changes once changes once again. At this again. At this point, you will point, you will have reached the have reached the inferior margin of inferior margin of the liver.the liver.

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Examination of Liver (Percussion)Examination of Liver (Percussion)

Upper margin is Upper margin is noted by noted by first dull first dull percussionpercussion note note

Lower margin is Lower margin is noted by noted by first first tympanitictympanitic note note

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To determine the size of the liver

The resonant tone produced by percussion over the anterior chest wall will be somewhat less drum like then that generated over the intestines. While they are both caused by tapping over air filled structures, the ribs and pectoralis muscle tend to dampen the sound.

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Examination of SpleenExamination of Spleen(Percussion)(Percussion)

Percussion at Castell’s SpotPercussion at Castell’s Spot

Castell’s Spot identifiedCastell’s Spot identified

Left anterior axillary line identifiedLeft anterior axillary line identified

Left lower costal margin identifiedLeft lower costal margin identified

Percussion at Castell’s Spot while patient Percussion at Castell’s Spot while patient inhales and exhales deeplyinhales and exhales deeply

Dull tone indicates Dull tone indicates possible possible splenomegalysplenomegaly

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Spleen percussionSpleen percussion

Enlarged spleen Enlarged spleen produce a produce a dull dull tonetone, in the , in the left left upper quadrant upper quadrant percussionpercussion but but should then be should then be verified by verified by palpation.palpation.

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Shifting DullnessThis is a test for peritoneal fluid (ascites). ++• Percuss the patient's abdomen to outline areas of dullness and tympany. • Have the patient roll away from you. • Percuss and again outline areas of dullness and tympany. If the dullness has

shifted to areas of prior tympany, the patient may have excess peritoneal fluid.

Psoas SignThis is a test for appendicitis. ++• Place your hand above the patient's right knee. • Ask the patient to flex the right hip against resistance. • Increased abdominal pain indicates a positive psoas sign.

Obturator Sign• This is a test for appendicitis. ++• Raise the patient's right leg with the knee flexed. • Rotate the leg internally at the hip. • Increased abdominal pain indicates a positive obturator sign.

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ILIOPSOAS TEST

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4. PALPATIONGeneral Palpation1. Begin with light palpation.

At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient's facial expression (so watch the patient's face, not your hands). Voluntary or involuntary guarding may also be present.

2. Proceed to deep palpation after surveying the abdomen lightly. Try to identify abdominal masses or areas of deep tenderness

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Abdominal Palpation Abdominal Palpation

Technique Technique

Light Light

Deep Deep

Liver edge Liver edge

Spleen tip Spleen tip

Kidneys Kidneys

Aorta Aorta

MassesMasses

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Abdominal palpationAbdominal palpation

To palpate four To palpate four quadrantsquadrants superficially superficially from LLQ from LLQ counterclockwisecounterclockwise

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Light PalpationLight Palpation

First First warm your warm your handshands by rubbing by rubbing them together before them together before placing them on the placing them on the patient.patient.

Abdominal wall Abdominal wall depressed depressed approximately 1 cmapproximately 1 cm

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Abdominal palpationAbdominal palpation

Use pads of three fingers of one hand and a light, gentle, dipping maneuver to examine abdomen

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Palpation (light)

Any areas of pain or tenderness are reserved for evaluation at the end of the exam

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Light PalpationLight Palpation

Mostly looking for Mostly looking for areas of areas of tendernesstenderness

Tenderness is a Tenderness is a physical examphysical exam finding finding a reflex occurs a reflex occurs (muscle splinting, (muscle splinting, wide eyes, moaning, wide eyes, moaning, teeth grittingteeth gritting). ).

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Palpation Light palpation assesses

Muscle tone Cutaneous hypersensitivity (suggests peritoneal irritation)

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Palpation Light palpation assesses

Presence of superficial (intramural) masses is more prominent if patient raises their head ,Intra-abdominal mass is less prominent if patient raises their head

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Palpation (deep)

Entire palm

Either one- or two handed technique is acceptable

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Deep PalpationDeep PalpationUse palmar surface of fingers of one hand (greatest number of greatest number of fingers)fingers) and a deep, firm, gentle maneuver to examine abdomen

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  PalpationPalpation

Palpate deeply with Palpate deeply with finger finger padspads (do not (do not “dig in” with finger “dig in” with finger tipstips))

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Deep PalpationDeep PalpationPalpate tender areas Palpate tender areas lastlast

Try to identify Try to identify abdominal abdominal massesmasses or or areas of areas of deep deep tendernesstenderness

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Two handed technique

When deep When deep palpation is palpation is difficult, examiner difficult, examiner may want to use may want to use left hand placed left hand placed over right handover right hand to to help exert pressurehelp exert pressure

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Palpation (deep)

Push as deeply as patient will allow without significant discomfort

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Normal structure that may be Normal structure that may be palpablepalpable

Sigmoid colon Sigmoid colon

LiverLiver

KidneyKidney

Abdominal aortaAbdominal aorta

Iliac arteryIliac artery

Distended bladderDistended bladder

Gravid and non-Gravid and non-gravid uterus gravid uterus

Xyphoid processXyphoid process

spleen spleen

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Abdominal massAbdominal mass

Intra abdominal Intra abdominal masses or masses or enlargements of the enlargements of the liver, gallbladder or liver, gallbladder or spleenspleen

Abdominal wall massAbdominal wall mass

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Intra abdominal masses or enlargements of Intra abdominal masses or enlargements of the liver, gallbladder or spleenthe liver, gallbladder or spleen

They will They will shift downshift down with inspiration and with inspiration and backback with with expiration.expiration. (not true of masses (not true of masses within the within the abdominal abdominal wallwall or or retroperitoneal retroperitoneal structuresstructures).).

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Aabdominal wall massAabdominal wall mass

It will become more It will become more evident and palpable evident and palpable when patient when patient flexes flexes neckneck as this as this contracts contracts rectus musclesrectus muscles. .

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Paraumbilical node Paraumbilical node

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Type of abdominal painType of abdominal pain

Visceral painVisceral pain Somatic painSomatic pain

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Visceral painVisceral pain

This is pain that arises This is pain that arises from an from an organic lesion organic lesion or functional or functional disturbance within an disturbance within an abdominalabdominal viscus viscus ((dulldull, , poorly poorly localizedlocalized, and , and difficultdifficult for the for the patient to patient to characterizecharacterize))..

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Somatic painSomatic pain

Painful lesion of the Painful lesion of the skinskinSharp, bright, and Sharp, bright, and well localizedwell localized Indicates Indicates involvement of involvement of parietal peritoneumparietal peritoneum or the or the abdominal abdominal wall itselfwall itself

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TendernessTenderness

If there is tenderness If there is tenderness determine the point of determine the point of maximum tendernessmaximum tenderness and its and its distributiondistribution

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Abdominal muscle spasmAbdominal muscle spasm

Voluntary guardingVoluntary guarding Tensing abdominal Tensing abdominal muscles due to muscles due to patient anxiety, patient anxiety, ticklishness, or ticklishness, or toprevent palpation to toprevent palpation to a painful area a painful area

Involuntary guardingInvoluntary guarding Muscular spasm or Muscular spasm or rigidity due to rigidity due to peritoneal peritoneal inflammationinflammationMay be localized May be localized (early appendicitis )or (early appendicitis )or diffuse (perforated diffuse (perforated bowel) bowel)

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Board-like rigidityBoard-like rigidityIf abdominal wall is If abdominal wall is palpated as obviously palpated as obviously tense, even as tense, even as rigid rigid as a board,as a board, board-like board-like rigidity is so called. Is rigidity is so called. Is caused by the spasm caused by the spasm of abdominal muscle of abdominal muscle due to peritoneal due to peritoneal irritation.irritation.

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Differential diagnosis of abdominal Differential diagnosis of abdominal painpain

Spine Spine pain pain

Abdominal wall Abdominal wall pain( differentiated by pain( differentiated by having the patient having the patient tense his abdominal tense his abdominal muscles, by forcefully muscles, by forcefully elevating his head elevating his head while keeping his while keeping his shoulders flat on the shoulders flat on the table)table)

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Liver palpation Liver palpation ((Standard Method)Standard Method)

Start in the Start in the RUQ,10 RUQ,10 centimeterscentimeters below the below the rib marginrib margin in the mid- in the mid-clavicular line clavicular line

Place Place left hand left hand posteriorlyposteriorly parallel to parallel to and supporting 11th & and supporting 11th & 12th ribs on right. 12th ribs on right.

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Standard Method Liver palpationStandard Method Liver palpation

Ask the patient to Ask the patient to take a take a deep breath.deep breath.

You may feel the You may feel the edge of the liver press edge of the liver press against your fingers. against your fingers.

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Liver palpation Liver palpation ((Standard Method)Standard Method)

Palpating hand is Palpating hand is held steadyheld steady while while

patient inhalespatient inhales

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Liver palpation Liver palpation ((Standard Method)Standard Method)

Palpating hand is Palpating hand is lifted and movedlifted and moved while the patient while the patient

breathes outbreathes out

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Liver palpationLiver palpation

Another method of Another method of palpating the liver palpating the liver uses the radial border uses the radial border of the index finger. In of the index finger. In this method the this method the anterior hand is anterior hand is placed flat on the placed flat on the anterior abdominal anterior abdominal wall with fingers wall with fingers parallel to the costal parallel to the costal margin margin

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Alternate Method Liver palpationAlternate Method Liver palpation

Is useful when the Is useful when the patient is patient is obese obese or or when the when the examiner examiner is smallis small compared compared

to the patient.to the patient.

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Alternate Method Liver palpationAlternate Method Liver palpation

Stand by the patient's Stand by the patient's chest.chest.

"Hook""Hook" your fingers your fingers just below the costal just below the costal margin and press margin and press firmly. firmly.

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HepatomegalyHepatomegaly

More than More than 1cm below1cm below the costal marginthe costal margin

An exception is a An exception is a congenitally large congenitally large right loberight lobe of the liver of the liver

Severe, chronic Severe, chronic emphysemaemphysema

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Pulsation transmitted from aorta Pulsation transmitted from aorta Tricuspid valve insufficiencyTricuspid valve insufficiency

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Hepatojugular reflux Hepatojugular reflux signsign

If you press the liver, If you press the liver, you will find the you will find the dilated jugular vein dilated jugular vein becomes more becomes more bulged or distended, bulged or distended, as from the as from the enlargement of liver enlargement of liver passive congestionpassive congestion resulted from resulted from right right failurefailure..

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Ballotable signBallotable sign

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Palpation of the LiverStandard Method• Place your fingers just below the right costal

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

against your fingers. Or it may slide under your hand as the patient exhales. A normal liver is not tender.

Alternate Method• This method is useful when the patient is

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

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

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

against your fingers.

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Spleen palpation Spleen palpation

SeldomSeldom palpable in palpable in normal adults. normal adults. Causes include Causes include COPDCOPD, and deep , and deep inspiratory descent of inspiratory descent of the diaphragm. the diaphragm.

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Spleen palpation Spleen palpation

Support Support lower left rib lower left rib cagecage with left hand with left hand while patient is supine while patient is supine and and lift anteriorly on lift anteriorly on the rib cagethe rib cage. .

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Spleen palpation Spleen palpation

Palpate Palpate upwards upwards toward spleentoward spleen with with finger tips of right finger tips of right hand, starting below hand, starting below left costal margin. left costal margin.

Have the Have the patient take patient take a deep breatha deep breath. .

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Examination of Spleen (Palpation)

Deep technique used

Starting point is RLQ, proceeding to LUQ

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Kidney palpationKidney palpation

Place Place left hand left hand posteriorlyposteriorly just below just below the right 12th rib. Lift the right 12th rib. Lift upwards. upwards.

Palpate deeply with Palpate deeply with right hand on anterior right hand on anterior abdominal wall.abdominal wall.

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Examination of Kidney

Patient take a Patient take a deep deep breath. breath.

Feel lower pole of Feel lower pole of kidneykidney and try to and try to capture it between capture it between your hands.your hands.

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Examination of Kidney

Right kidney may be felt to slip between hands during exhalation

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Examination of Aorta

Flat palm placed over the the epigastrium to locate pulse

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Examination of Aorta

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

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

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Examination of Aorta

Hands then oriented vertically on either side of midline with distal fingers at level of pulsation; equal pressure applied until pulsation is palpated

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

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Examination of Aorta

Lateral width of pulsation is determined by space between index fingers

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PEMERIKSAAN ABDOMENPEMERIKSAAN ABDOMEN

Special examSpecial exam

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Special examSpecial examMurphy’s Sign Murphy’s Sign McBurney’s McBurney’s PointPointRovsing’s SignRovsing’s SignPsoas SignPsoas SignObturator Obturator SignSign

Re bound Re bound TendernessTenderness

Costovertebral Costovertebral tendernesstenderness

Shifting Shifting DullnessDullness

Fluid waveFluid wave

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Murphy’s Sign (acute cholecystitis)Murphy’s Sign (acute cholecystitis)

Examiner’s hand is at Examiner’s hand is at middle inferior border middle inferior border of liver.of liver.Patient is asked to Patient is asked to take take deep inspirationdeep inspiration..If positive patient will If positive patient will experience painexperience pain and and will will stop shortstop short of full of full inspirationinspiration

Hepatitis, subdiaphragmatic Hepatitis, subdiaphragmatic abscess Cholecystitisabscess Cholecystitis

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McBurney’s PointMcBurney’s Point

Localized tenderness Localized tenderness Just below Just below midpoint midpoint of line between of line between right right anterior iliac crestanterior iliac crest and and umbilicusumbilicus..

Heel strikeHeel strike, , riding riding over bumpsover bumps in road in road while while drivingdriving,, coughingcoughing, will , will produce pain.produce pain.

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McBurney’s Point (McBurney’s Point (Common CausesCommon Causes))

Appendicitis Incarcerated or Incarcerated or strangulated hernia strangulated hernia Ovarian torsion (twisted Ovarian torsion (twisted Fallopian tube) Fallopian tube) Pelvic inflammatory disease Abdominal abscess Hepatitis Diverticular disease Diverticular disease Meckel''s diverticulumMeckel''s diverticulum

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Rovsing’s SignRovsing’s Sign

Patient will Patient will experience right lower experience right lower quadrant pain (in quadrant pain (in region of McBurney’s region of McBurney’s Point) when left lower Point) when left lower quadrant is palpated. quadrant is palpated.

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Non-Classical AppendicitisNon-Classical Appendicitis

Iliopsoas SignIliopsoas Sign

Obturator SignObturator Sign

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Iliopsoas SignIliopsoas Sign

Patient can lay on side and extend leg at the hip Patient can lay on side and extend leg at the hip or have patient lay on back and try to flex hip or have patient lay on back and try to flex hip against the resistance of examiner’s hand on against the resistance of examiner’s hand on thigh. If patient has an inflamed retrocecal thigh. If patient has an inflamed retrocecal appendix, this will produce pain. appendix, this will produce pain.

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Iliopsoas SignIliopsoas Sign

Anatomic basis for Anatomic basis for the psoas sign: the psoas sign: inflamed appendix is inflamed appendix is in a retroperitoneal in a retroperitoneal location in contact location in contact with the psoas with the psoas muscle, which is muscle, which is stretched by this stretched by this maneuver. maneuver.

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Obturator SignObturator Sign

Internally rotate right leg at the hip with the knee Internally rotate right leg at the hip with the knee at 90 degrees of flexion. Will produce pain if at 90 degrees of flexion. Will produce pain if inflamed appendix is in pelvis. inflamed appendix is in pelvis.

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Obturator SignObturator Sign

Anatomic basis for Anatomic basis for the obturator sign: the obturator sign: inflamed appendix in inflamed appendix in the pelvis is in contact the pelvis is in contact with the obturator with the obturator internus muscle, internus muscle, which is stretched by which is stretched by this maneuver. this maneuver.

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Rebound TendernessRebound Tenderness ((FFor peritoneal irritation)or peritoneal irritation)

WarnWarn the patient what the patient what you are you are about to doabout to do. .

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

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

If it If it hurts more when you hurts more when you release,release, the patient has the patient has rebound tenderness. [rebound tenderness. [4] ]

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Cost vertebral TendernessCost vertebral Tenderness (Often with renal disease)(Often with renal disease)

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

CompareCompare the the left left and right sides. and right sides.

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Warn the patient Patient sit up on the exam tableWarn the patient Patient sit up on the exam table

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Shifting DullnessShifting Dullness ((FFor peritoneal fluid)or peritoneal fluid)

Percuss Percuss from anterior abdomen laterally to to outline areas of outline areas of dullness dullness noted

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Examination for Shifting Dullness

Patient rolled slightly toward the examined side; movement of the dull point medially is described as “shifting dullness” and suggests ascites

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Shifting DullnessShifting Dullness

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Fluid waveFluid wave

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CONTRAINDICATIONS FOR ABDOMINAL ASSESSMENT

• NEVER PALPATE IF SUSPECTED APPENDICITIS OR DISSECTING ABD. AORTIC ANEURSYM

• NEVER PALPATE WITH POLYCYSTIC KIDNEYS

• DO NOT PALPATE OF PERCUSS TRANSPLANTED ORGANS