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The Abdominal Examination Prepared by: Dr. Mohammad Shaikhani. Assistant professor, Sulaymanyiah University. Kurdistan Center for GIT/Hepatology. References: Liviu Lefter MD, PhD,Clinical Tutor, UTAS H.A.Soleimani MD, Gastroenterologist Other web-based anonymous presentations.
I nspection: General 1. Cachexia of cirrhosis or cancer evident by temporal recession / or wasted muscles. 2. Jaundice. 3. Pallor. 4. Vircow’s Node: left supraclavicular LN enlargement. 5. Clubbing, palmar erythem, white nails, duptryn contracture. 6. Leg edema. 7.Gynecmastia. 8. Mouth ulcers of IBD, Peutz-gagher perioral pigmentation, talangiectasia of HHT, MOUTH THRUSH.
Respiratory movement - In men / children, manner of breathing is abdominal respiration. - In women the manner of breathing is thoracic respiration. - Respiratory movement is limited (could suggest peritonitis).
Gastric or intestinal pattern / peristalsis - In healthy person peristalsis is not visible - Becomes spontaneously visible or provoked by percussion in bowel obstruction
The edge should be soft, sharp and regular, with a smooth surface
The normal liver may be slightly tender
On inspiration, the liver is palpable about 3 cm below the right costal margin in the midclavicular line
If you start too high, you may miss the liver
Can also consider the hooking technique
LIVER SPAN PERCUSSION PALPATION PERCUSSION SCRATCH TEST NL < 12-13 CM MCL 2-3 CM DURING INSPIRATION AND EXPIRATION COPD LIVER SPAN MAY VARY BETWEEN OBSERVERS DEPENDING UPON WHERE THE MCL IS DETERMINED JAMA 1994;271:1859-1865
RESONANCE LIVER SPAN - PERCUSSION CONSIDER USING MULTIPLE PLEXIMETERS AIR JAMA 1994;271:1859-1865 DULLNESS
Percussion: Liver span The liver span is estimated by percussion. Remember that it is easier to hear the change from resonance to dullness – so proceed with percussion from areas of resonance to areas of dullness. Upper border: In the midclavicular line start percussing in the chest moving down towards the abdomen about ½ to 1 cm at a time. Note where the percussion notes change from resonate to dull. Lower border: In the midclavicular line begin percussion below the unbillicus and proceed upward until dullness is encounter. The distance between the two areas where dullness is first encountered is the liver span. Liver span is normally 6 to 12 cm in the midclavicular line.
SCRATCH TEST USED TO IDENTIFY THE INFERIOR BORDER OF THE LIVER STETHOSCOPE IS PLACED OVER THE LIVER IN THE MCL SCRATCHES ARE PRODUCED BEGINNING IN THE RLQ AND MOVING THE FINGER CEPHALAD IN THE MCL. A CHANGE IN THE UNDERLYING TISSUE (INFERIOR LIVER EDGE) IS IDENTIFIED BY THE CHANGE IN SOUND INTENSITY. BEGIN MOVEMENT MOSBY’S GUIDE TO PHYSICAL EXAMINATION 3 RD ED,1995
Liver Span: Scratch Test Start in the same areas above and below the liver as you would with percussion. Instead of percussing lightly, scratch moving your finger back and forth while listening over the liver. Since sound is conducted better in solids than in air, when the louder sounds are heard you are over the liver. Mark the superior and inferior boarders of the liver span in the midclavicular line
COURVOISIER’S SIGN – A PALPABLE NONTENDER GALL BLADDER IN A PATIENT WITH JAUNDICE SUGGESTING EXTRAHEPATIC OBSTRUCTUON OF THE BILIARY SYSTEM SECONDARY TO MALIGNANCY (ORIGINAL DESCRIPTION).
MURPHY’S SIGN – WITH THE EXAMINER’S FINGERS POSITIONED ALONG THE INFERIOR BORDER OF THE LIVER IN THE RIGHT COSTAL ARCH THE PATIENT IS ALLOWED TO INSPIRE. DURING INSPIRATION THE INFLAMED GALLBLADDER TOUCHES THE EXAMINERS FINGERS RESULTING IN THE SUDDEN CESSATION OF INSPIRATION.
BOAS’ SIGN – HYPERESTHESIA & REFERRED PAIN TO THE RIGHT COSTOPHRENIC ANGLE IN PATIENT’S WITH ACUTE CHOLECYSTITIS.