Abdominal examination

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it's how ur doc examine ur abdomen.

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Abdominal examination

  1. 1. ABDOMINAL EXAMINATION 3 rd June Dr. YL Cheong
  2. 2. General Condition <ul><li>Consciousness, confuse </li></ul><ul><li>Gait </li></ul><ul><li>ill-looking </li></ul><ul><li>Built </li></ul><ul><li>Hydration </li></ul><ul><li>Color, pallor, cyanosis, jaundice, carotinaemia </li></ul><ul><li>Stigmata of liver disease </li></ul><ul><li>Fetor </li></ul>
  3. 4. ABDOMINAL EXAMINATION <ul><li>Inspection </li></ul><ul><li>Palpation </li></ul><ul><li>Percussion </li></ul><ul><li>Auscultation </li></ul><ul><li>Per rectal examination </li></ul><ul><li>Hernia and scrotum </li></ul>
  4. 7. ABDOMINAL EXAMINATION <ul><li>Patient lying down supine </li></ul><ul><li>Bed </li></ul><ul><li>Pillow supporting head </li></ul><ul><li>Hands by side of body </li></ul><ul><li>Examiner sitting down on the right of patient </li></ul><ul><li>Patient adequately expose </li></ul>
  5. 9.
  6. 10. INSPECTION <ul><li>Normal abdomen: </li></ul><ul><li>Scaphoid </li></ul><ul><li>Moves with respiration </li></ul>
  7. 11. ABNORMAL ABDOMEN <ul><li>Distended </li></ul><ul><li>Everted umbilicus </li></ul><ul><li>Dilated veins </li></ul><ul><li>Ecchymosis </li></ul><ul><li>Striae </li></ul><ul><li>Pigmentation </li></ul><ul><li>Surgical scars </li></ul><ul><li>Peristalsis </li></ul>
  8. 12. DISTENDED ABDOMEN <ul><li>Feces </li></ul><ul><li>Fat </li></ul><ul><li>Fluid </li></ul><ul><li>Flatus </li></ul><ul><li>Fetus </li></ul>
  9. 13. EVERTED UMBILICUS <ul><li>Ascites </li></ul><ul><li>Umbilical hernia </li></ul><ul><li>Paraumbilical hernia </li></ul>
  10. 17. DILATED VEINS <ul><li>Caput medusae secondary to portal hypertension </li></ul><ul><li>Dilated upward flowing veins secondary to IVC obstruction </li></ul>
  11. 21. ECCHYMOSIS <ul><li>Cullen sign </li></ul><ul><li>Grey Turner sign </li></ul>
  12. 23. STRIAE <ul><li>Whitish—stretch marks or striae gravidarum </li></ul><ul><li>Purplish—Cushing disease or syndrome </li></ul>
  13. 25. PIGMENTATION <ul><li>Linea nigra in pregnancy </li></ul><ul><li>Addison disease </li></ul><ul><li>Café au lait—Von Recklinhausen (neurofibromatosis ) </li></ul><ul><li>Vitiligo—loss of pigmentation </li></ul>
  14. 27. SURGICAL SCARS <ul><li>Names and sites of incision </li></ul><ul><li>Reddish– recent </li></ul><ul><li>Whitish—old </li></ul><ul><li>Stretch—likely incisional hernia </li></ul>
  15. 29. PERISTALSIS <ul><li>Thin patients: visible </li></ul><ul><li>Intestinal obstruction </li></ul>
  16. 33. PELVIC ORGANS <ul><li>Urinary bladder </li></ul><ul><li>Gravid uterus </li></ul><ul><li>Ovarian tumuor </li></ul>
  17. 36. PALPATION <ul><li>Right side of patient </li></ul><ul><li>Sitting down </li></ul><ul><li>Hands and forearm at level of patient’s abdomen </li></ul><ul><li>Looking at patient’s face all the time </li></ul><ul><li>Two rounds of palpation—superficial and deep </li></ul><ul><li>Systematically—clockwise or anticlockwise </li></ul><ul><li>Usually the non tender side first </li></ul>
  18. 42. LIVER <ul><li>Right subcostal region </li></ul><ul><li>Normally not palpable </li></ul><ul><li>Enlargement measure in cm. or finger breadths below right costal margin </li></ul><ul><li>Descend with inspiration </li></ul><ul><li>Not able to get above it </li></ul><ul><li>Non ballotable </li></ul><ul><li>Liver span ( percussion ) </li></ul>
  19. 46. SPLEEN <ul><li>Left subcostal region </li></ul><ul><li>Normally not palpable </li></ul><ul><li>Enlarges three times before palpable </li></ul><ul><li>Descend downwards and medially with inspiration </li></ul><ul><li>Cannot get above it </li></ul><ul><li>Splenic notch </li></ul><ul><li>Non ballotable </li></ul><ul><li>Traube’s space dull on percussion (10 th , 11 th and 12 th intercostal space midaxillary line) </li></ul>
  20. 51. Kidneys <ul><li>Normally non palpable </li></ul><ul><li>Sometimes in thin patients – right lower pole can be felt </li></ul><ul><li>Descends downwards with respiration </li></ul><ul><li>Ballotable </li></ul><ul><li>Cannot get above it </li></ul><ul><li>Resonant to percussion </li></ul>
  21. 54. PELVIC ORGANS <ul><li>Urinary bladder, uterus, ovarian tumour </li></ul><ul><li>Unable to ‘ get below it ‘ </li></ul><ul><li>Globular in shape </li></ul><ul><li>Dull on percussion in the centre </li></ul><ul><li>Internally ballotable </li></ul>
  22. 57. ABDOMINAL AORTA <ul><li>Palpable in thin patients </li></ul><ul><li>Deep palpation slightly above and left of umbilicus </li></ul><ul><li>Use fingertips </li></ul><ul><li>Aneurysm of aorta—expansile pulsation cf. to transmitted pulsation </li></ul>
  23. 61. FEMORAL ARTERY <ul><li>Mid inguinal point—between ASIS and symphysis pubis </li></ul><ul><li>Midpoint of inguinal ligament—between ASIS and pubic tubercle, 2cm. above is the internal ring ( indirect inguinal hernia ) </li></ul>
  24. 63. TENDERNESS <ul><li>Sign of inflammation ( rubor, calor, dolor, tumor and loss of function ) </li></ul><ul><li>Local– epigastrium, pelvic, RIF </li></ul><ul><li>Generalised –peritonitis </li></ul>
  25. 65. TENDERNESS <ul><li>Rebound tenderness </li></ul><ul><li>Contralateral tenderness ( Rovsing sign ) </li></ul><ul><li>Murphy sign—arrest of inspiration with a gasp when patient takes a deep breath as the gallbladder is palpated ( acute cholecystitis ) </li></ul><ul><li>Guarding– local or generalised </li></ul><ul><li>Board-like rigidity </li></ul>
  26. 66. COURVOISIER’S LAW <ul><li>In the presence of jaundice, a palpable gallbladder is unlikely to be due to gallstone </li></ul><ul><li>More likely to be due to carcinoma eg, carcinoma of head of pancreas </li></ul>
  27. 67. PERCUSSION <ul><li>The middle finger ( pleximeter finger ) of the left hand is placed on the part of the body to be percussed and the back of its middle phalange is then struck with the tip of the middle finger of the right hand </li></ul>
  28. 68. PERCUSSION <ul><li>Dullness </li></ul><ul><li>Shifting dullness </li></ul><ul><li>Resonance </li></ul>
  29. 71. DULLNESS <ul><li>Liver span </li></ul><ul><li>Traube’s space—enlarged spleen; dullness in 10 th , 11 th and 12 th intercostal space at mid axillary line </li></ul><ul><li>Margin of enlarged organs—sometimes easier to define by percussion than palpation eg. Urinary bladder, ovarian tumour </li></ul><ul><li>Ascites– small amount use shifting dullness. Large amount use fluid thrill </li></ul>
  30. 72. RESONANCE <ul><li>Presence of air </li></ul><ul><li>Hyper-resonance – intestinal obstruction and paralytic ileus </li></ul><ul><li>Loss of liver dullness—perforated peptic ulcer </li></ul>
  31. 73. GROSS ASCITES <ul><li>Dull in flanks </li></ul><ul><li>Umbilicus transverse and or hernia present </li></ul><ul><li>Shifting dullness positive </li></ul><ul><li>Fluid thrill presence </li></ul>
  32. 77. LARGE OVARIAN CYST <ul><li>Resonance in flanks </li></ul><ul><li>Umbilicus vertical and drawn up </li></ul><ul><li>Large swelling felt arising out of pelvis and one cannot ‘get below it’ </li></ul>
  33. 78. URINARY BLADDER <ul><li>Dullness suprapubically </li></ul><ul><li>Resonance superiorly and in the flanks </li></ul>
  34. 79. INTESTINAL OBSTRUCTION <ul><li>Resonance throughout </li></ul><ul><li>Colicky pain ( no pain in paralytic ileus ) </li></ul><ul><li>Vomiting </li></ul><ul><li>Constipation </li></ul><ul><li>Absence of flatus </li></ul>
  35. 81. AUSCULTATION <ul><li>Bowel sounds </li></ul><ul><li>Sucussion splash </li></ul><ul><li>Vascular bruit </li></ul>
  36. 82. BOWEL SOUNDS <ul><li>Right of umbilicus for a minute </li></ul><ul><li>Not move from place to place </li></ul><ul><li>Normal sounds– sometimes can be heard without stethoscope esp. when hungry </li></ul><ul><li>Acute small bowel obstruction—loud, excessive and exaggerated ( very angry) same time when the patient is feeling bouts of colicky pain </li></ul>
  37. 83. BOWEL SOUNDS <ul><li>Silent –no bowel sound heard after a minute of auscultation </li></ul><ul><li>Generalized peritonitis </li></ul><ul><li>Paralytic ileus </li></ul>
  38. 84. SUCUSSION SPLASH <ul><li>Patient supine </li></ul><ul><li>Stethoscope in epigastrium </li></ul><ul><li>Roll the patient side to side </li></ul><ul><li>Hear splashing sound if stomach or small intestines is filled with fluid </li></ul>
  39. 85. SUCUSSION SPLASH <ul><li>Pyloric stenosis– chronic peptic ulcer disease, ca pylorus </li></ul><ul><li>Mechanical bowel obstruction </li></ul><ul><li>Paralytic ileus </li></ul>
  40. 86. VASCULAR BRUIT <ul><li>Bruit over a blood vessel is a signicant finding indicating turbulent flow </li></ul><ul><li>Umbilicus– above and left ( abdominal aortic aneurysm or stenosis ) </li></ul><ul><li>Iliac fossa—iliac artery </li></ul><ul><li>Groin—femoral </li></ul><ul><li>Epigastrium –coeliac or superior mesenteric artery </li></ul><ul><li>Mid abdomen either side of midline—renal artery stenosis </li></ul><ul><li>Liver—hepatoma </li></ul><ul><li>Thyrotoxicosis--neck </li></ul>
  41. 87. HERNIAS <ul><li>Inguinal hernia—direct and indirect </li></ul><ul><li>Femoral </li></ul><ul><li>incisional </li></ul>
  42. 88. HERNIA <ul><li>Protusion of a viscus through a weakness in the wall </li></ul><ul><li>Produce by standing, straining or coughing </li></ul><ul><li>Reduce by lying down </li></ul>
  43. 91. INGUINAL HERNIA <ul><li>Neck of sac—above and medial of pubic tubercle </li></ul><ul><li>Above inguinal ligament </li></ul><ul><li>Indirect enters scrotum </li></ul><ul><li>Direct does not </li></ul><ul><li>Occlusion of internal ring– indirect hernia not emerge; direct will come out </li></ul>
  44. 97. FEMORAL HERNIA <ul><li>Neck of sac—below and lateral to pubic tubercle </li></ul><ul><li>Below inguinal ligament </li></ul>
  45. 99. INCISIONAL HERNIA <ul><li>Previous abdominal incisions </li></ul>
  46. 101. SCROTAL MASS <ul><li>‘ can get above’ the scrotal mass </li></ul><ul><li>If unable– it is an inguinal hernia </li></ul>
  47. 103. PER RECTAL EXAMINATION
  48. 107. ABDOMINAL MASS <ul><li>Intra or extra abdomen ( inside or outside the abdominal cavity? </li></ul><ul><li>Lift the head up to tense the abdominal muscle </li></ul><ul><li>If intra– mass is less obvious </li></ul><ul><li>If extra or in the wall—mass is the same </li></ul>
  49. 108. ABDOMINAL MASS <ul><li>Site—organs below </li></ul><ul><li>Size and shape </li></ul><ul><li>Surface ,edge and consistency—hard and nodular implies neoplasm </li></ul><ul><li>Regular, round, smooth and tense– likely to be a cyst </li></ul><ul><li>Solid, ill defined an tender – inflammatory mass </li></ul>
  50. 109. MASS <ul><li>Mobility— </li></ul><ul><li>Moves with inspiration—liver, spleen, kidneys, gallbladderand distal stomach and cannot ‘get above it’ </li></ul><ul><li>Not move—rest of intestine and omentum but mobile on palpation </li></ul><ul><li>Completely fixed—retroperitoneal organs eg.pancreas; advanced neoplasm fixed to abdominal walls or inflammatory mass </li></ul><ul><li>Fibroid or gravid uterus moves side to side </li></ul><ul><li>Bladder or ovary fixed </li></ul>
  51. 110. ABDOMINAL MASS <ul><li>Ballotable or bimanually palpable </li></ul><ul><li>kidneys </li></ul>
  52. 111. ABDOMINAL MASS <ul><li>Pulsatile </li></ul><ul><li>Transmitted or expansile </li></ul>
  53. 114. <ul><li>HOW TO BE SKILLFUL IN ABDOMINAL EXAMINATION? </li></ul><ul><li>3 WAYS: </li></ul><ul><li>Practice </li></ul><ul><li>More practice </li></ul><ul><li>Practice, practice, practice and more practice </li></ul>
  54. 115. <ul><li>THE END </li></ul>

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