1. Acute Ischemic Stroke
Presenter: Dr. Zeleke W/Y (NR-II)
Moderator: Dr. Nebiyu B.(Consultant Neurologist)
Dr. Guadie B.(Consultant Neurologist)
Date: Jan 20,2023
2. Some Historical points(aspects)
1.Deglutitive complaints
• Odynophagia-painful swallowing
E.g moniliasis,viral infection
• Dysphagia-difficulty in swallowing
E.g Achalasia, diffuse spasm
• Aphagia-failure to swallow
E.g total esophageal obstruction
• Phagophobia-fear of swallowing
E.g tetanus,rabies
3. 2. Pyrosis (heart burn)
E.g GERD (reflux esophagitis)
3.Abdominal pain.
Site of pain?
• Epigastric
• Right upper quadrant
• Peri umbilical
• Iliac fossa
• Supra pubic
4. Nature of pain (character)?
• Burning
• Colicky
• Aching
• Crampy
Direction of radiation?
• RUQ to right shoulder-cholecystits
• Epigastric to back-peptic ulcer disease
• Flank to inguinal-renal stone
9. Abdominal physical examination
Format-
• Paitent must be recumbent-1 pillow
• Good light source
• Hands by his/her sides
• Clothes drawn above pubis
• Bladder should be empty
• Examiner should be on the right side of patient
A.Inspection
• General shape of abdomen-scaphoid,flat,full,
10. If full or distended,is it generalized or localized?
Are flanks full? Is it symmetrcal?
Physiological causes- full bladder,fetus,feces & flatus
• Visible pulsations? Where?
Epigastric
• Transmitted from aorta
• Hyperkinetic right ventricle
• Growth in front of aorta
• Aortic aneurysm
Movement of abdominal wall
• During breathing –abdominal paradox shows
paralysis of diaphragm
11. • Absence of movement - peritonitis
• Visible peristalsis - obstruction
• Large bowl obstruction - peripheral distention
• Small bowl obstruction- central distention with
ladder appearance
• Pyloric obstruction- a ‘J’ shaped enlarged stomach
with succusion splash
Surface of abdomen
• Striae-are white ,lilac lines in epidermis e.g
obesity,pregnancy,cushing,wasting diseases
• Visible surface veins lateral
vein-inferior venacaval obstruction
12. Epigastric (superior & inferior) and caput medusae-
portoparietal anastomosis
• Pigments-linea nigra e.g pregnancy
Umblicus
Appearance & position- inverted,flat,everted?
Umblical slit-circular,vertical ,horizontal?
• Look for hernial sites
B.Palpation
Principals
• Hand flat & horizontal, move from the
matecarpophalengial joints
13. • Avoid finger tips
• Organs in upper quadrants felt with radial border
of index finger during inspiration
• Lateral regions or organs felt by bimanual palpation
• First ask for any area of pain or tenderness
• Move systematic – quadrant by quadrant
RHQ LHQ
RLQ LLQ
XYPHI
UMBICUS
14. Superficial palpation
• Single hand-look for rigidity
• Tenderness –normal abdomen is non tender
Deep palpation
For masses,enlarged organs. If any mass felt describe-
• Its position in abdomen
• Extends from coastal marigins?
• Arises from pelvis?
• Size,character,mobility & its attachment?
• Surface smooth,hard or firm?
• Marigins/edges sharp or rounded?
Localized
Generalized
15. C.Percussion
• Normal abdomen is tympanetic except for liver & splenic dullness and full
bladder
• Increase in splenic dullness is enlargement or rupture
• Absent liver dullness- gas in peritonium,emyphesema or pneumothorax
• When ascitus (free fluid) is present in peritonium-
Diffuse abdominal enlargment with full flanks
Presence of shifting dullness
Presence of fluid thrill when significant
amount of fluid is present
16. Differentiate ascites from ovarian cyst
Ascites Ovarian cyst
Bulge mainly lateral Anterioposterior
Chief dullness at flanks At center
Shifts when patient is moved No change in position
Umbilicus flat or everted Drawn up ward
Slit is transverse Slit is vertical
17. D.Auscultation
• Bowel sounds-absent or present?-tinkling mostly
• Borborygmi in bowel obstruction or diarrhea
• Systolic murmurs –vascular stenosis,anurysums
& artriovenous fistulas
• Venous hum(continuous humming sound) in anastomotic veins or varices.
Examining organs
1.Liver-palpate lower edge of liver.Edge sharp or rounded?
18. • Surface firm,smooth,nodular or hard? Tender? Irregular?
• Percuss-for the vertical span of the liver along the mid clavicular line.Normally 8-10
cm
2.The gall bladder
• Can’t be felt unless distended
• Movable from side to side
• Moves with respiration
• Elicit tenderness –Murphy’s sign in acute cholecystitis
3.Spleen
• Normally not palpable,
19. • Palpable when enlarged over twice its normal size
• If not very large (moderate),it may be palpated using both
hands by putting the patient on right lateral position
Characteristics of spleen
• Direction of growth is from LUQ down & medial to the
umblicus
• Has a medial notch
• Can’t pass your finger tips under the coastal marigin
20. • The edge is sharp
• Spleen is not bimanually palpable
• Auscultate for presence of friction rub over it
E.g splenic infarction,perisplenitis
RUQ LUQ
RLQ
LLQ
UMBLICUS
21. 4.Kidneys
• Patient lies flat (supine)
• Put one hand under the last rib posterior and the other
hand below the coastal marigin in front
• If enlarged, it can be trapped between the two hands
during inspiration (bimanual)
• The lower pole of the right kidney maybe palpable in thin
people
22. Distinguish between-
A .Movable right kidney from the gallbladder
• Distended gallbladder can be seen on inspection
• Can be pushed back,but springs forward again
• The right kidney disappears on expiration & can only be found again with difficulty
on inspiration
• Only kidney is bimanually palpated B.Enlarged left kidney from the spleen
• Spleen has a sharp edge with a medial notch
while kidney has a rounded edge
23. • Fingers can be passed under the coastal marigin over a renal mass (enlarged
kidney)
• Renal mass (enlargement) bimanually palpable
• Colonic resonance is detectable in front of a renal tumour (mass),but not in front of
a splenic enlargement.
END
