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  1. 1. AbdomenSymptoms & Local Exam
  2. 2. Symptoms of Digestive System:• 1- Dysphagia: difficulty in swallowing • Where does the food stick? • Oral dysphagia: dry mouth, painful condition, paresis of the tongue • Esophageal: the food is felt to stick in the throat or behind the sternum • Is it worse with liquids or solids? • Is swallowing painful „odynophagia‟?
  3. 3. Symptoms of Digestive System:• 2- Pain • Site • Radiation • Character • Severity • Duration • Frequency & periodicity • Aggravating factors • Relieving factors • Associated phenomena
  4. 4. Symptoms of Digestive System: 3- Heartburn: is a burning sensation experienced behind the sternum. In most cases it is due to reflux of acid into the esophagus. 4- Regurgitation: is rarely preceded by nausea and is often effortless
  5. 5. Symptoms of Digestive System: • 5- Vomiting • Frequency • Its relation to pain • Does it relieve pain or not? • Character of vomited matter? • Amount • Color: yellow color indicates bile • Smell: foul smelling; ulcerated cancer stomach, pyloric obst, fecal matter in intestinal obstruction
  6. 6. Symptoms of Digestive System: • Does it contain blood? • Does it look like “Coffee ground”? • Does it contain residue of food taken the day before?• 6-Nausea: Sensation of sickness without actual vomiting, frequently accompanied with salivation, sweating, and feeling of faintness
  7. 7. Symptoms of Digestive System:• 7- Hematemesis: Vomiting of blood • May be bright red or coffee ground • Ask about recent intake of aspirin, NSAID, alcohol, hist of peptic ulcer or chronic liver disease.• 8- Melena: passage of black, soft, tarry stool.
  8. 8. Symptoms of Digestive System:• 9- Disturbance of Appetite: • Loss of appetite (Anorexia): must be distinguished from fear of eating because of painful condition in the mouth or gut. • Excessive: • anxiety states • Thyrotoxicosis • DM
  9. 9. Symptoms of Digestive System: Filling of the mouth with• 10- Water brash: composed of saliva. • It is not necessarily a symptom of organic disease. • May be due to reflex stimulation of saliva from GIT lesion. usually indicates• 11- Eructation “Belching”: air swallowing of psychogenic origin. May occur in organic diseases.
  10. 10. Symptoms of Digestive System: It is a term that• 12- Dyspepsia/ Indigestion: usually describe a collection of symptoms. • Defined as pain or discomfort centered in the upper abdomen that may be associated with upper abdominal fullness, early satiety, bloating, belching, or nausea.
  11. 11. Symptoms of Digestive System:• 13- Constipation • Normal stool frequency varies between 3 times daily to 3 times weekly. • What is the normal patient habit? • Has there any recent change in habit? • If so, can this be explained by a change in diet, medicine….?
  12. 12. Symptoms of Digestive System:Constipation (cont’) • Does constipation alternate with diarrhea? • If so, can this be explained by taking purgatives? • Has he any colicky pain? • Has he had any vomiting? • Has he passed blood? • Has he any weight loss?
  13. 13. Symptoms of Digestive System:• 14- Diarrhea: • Number • Time of occurrence of motion during the day. • Their relation to meals or special kind of food. • Color of the motion • Consistency: formed, watery, frothy
  14. 14. Symptoms of Digestive System: • Do they float in the lavatory or difficult to flush away? Note: pale, bulky, soft, frothy and smelly stool is characteristic of “Steatorrhea” • Has he ever passed any blood? • Does the patient use purgatives? often accompanies diarrhea• 15- Tenesmus: and consists in straining with a desire to empty the lower bowel without complete evacuation taking place.
  15. 15. Symptoms of Digestive System:• 16-Flatulence: the patient may complain of winds or abdominal distension.• 17-Bleeding per rectum:
  16. 16. Symptoms of Digestive System:• 18- Jaundice: Yellowish discoloration of the skin and mucus membranes caused by the presence in the blood of an excess of bile pigments. • Color of urine and stool • Itching • History of Contact with jaundiced person.
  17. 17. Symptoms of Digestive System: Jaundice (cont’)• Injection ,dental procedure, tattooing, operation, blood transfusion.• Drug history, Alcohol intake.• Previous dyspepsia or biliary colic• Hist of weight loss.• Fever and rigors: cholangitis (stone,malign). Usually in viral hepatitis, the fever subsides with appearance of jaundice.
  18. 18. LocalExamination
  19. 19. Local Examination• Inspection• Palpation• Percussion• Auscultation: If you want to exam for intestinal sound, auscultation should be done after inspection• Pelvic, genital, and rectal examination are part of abdominal evaluation.
  20. 20. Anatomical Consideration• Think anatomically: imagine what organs live in the area you are examining.• The abdomen is roughly divided into 4 quadrants.
  21. 21. Think Anatomically• Another way is to divide the abdomen into 9 areas by: • 2 vertical lines (MCL), • 2 horizontal lines: • The upper at the level of 10th costal cartilage, • The lower at the level of the ant. Sup. Iliac spines
  22. 22. RHQ LHQ EpigastricR Lumbar L Lumbar Umbilical Hypogastric L Iliac R Iliac
  23. 23. Exposure of the Abdomen• Uncover the abdomen from just below the breast, to the pelvic brim.• Abd muscles should be relaxed. You can ask the pat to flex their knees to relax abd muscles.
  24. 24. I- Inspection• 1- Shape (contour) • Normal • Sunken (Scaphoid): as in starvation, malignancy. • Distension • Generalized: fat, fluid, flatus, feces, fetus • Localized: gross enlargement of an organ, or mass.
  25. 25. Normal Shape of the Abdomen
  26. 26. Obesity
  27. 27. Ascites
  28. 28. Ascites
  29. 29. Localized Enlargement
  30. 30. Inspection• 2- Umbilicus: i. Shape: normally slightly retracted and inverted. • Everted: as in umbilical hernia • Deeper than normal: obesity ii. Site iii. Nodules: malignancy iv. Pigmentation
  31. 31. Normal Umbilicus
  32. 32. Umbilicus is deeper than normalObesity
  33. 33. Inspection (cont’)• 3- Movement of the Abd. Wall i. Movement with respiration: absent of diminished with generalized peritonitis. ii. Visible pulsations iii. Visible peristalsis: • pyloric obst, • intestinal obstruction . • May be normal in elderly with thin abd wall (no history of pain)
  34. 34. Inspection (cont’)• 4- Skin: i. Smooth and shiny in marked distension. ii. Striae: • white or pink linear marks. • Produced by gross stretching of the skin with rupture of elastic fibers. • Indicates recent change in the size of the abdomen: preg, ascites, wasting diseases • Wide purple striae are characteristic of cushing and excessive steroid therapy iii. Scars
  35. 35. Striae
  36. 36. Scar
  37. 37. Inspection4- skin (cont’) iv. Abnormal veins: dilated, tortuous. Check direction of flow: • Portal hypertension: veins are centrally placed • IVC obstruction: on the sides of the abd. v. Hair distribution. vi. Pigmentation and rash.
  38. 38. Feminine Hair Distribution
  39. 39. Inspection• 5- Divarication of Recti• 6- Hernial orifices: • Better while the patient is standing • Ask him to cough • Look for expansile impulse
  40. 40. Divarication of Recti
  41. 41. Umbilical Hernia
  42. 42. More prominent with cough
  43. 43. Strangulated Umbilical Hernia
  44. 44. Inguinal Hernia
  45. 45. II- Palpation• 1- Superficial palpation: • Pain & Tenderness. • Rigidity • Superficial swelling.• 2- Deep Palpation • Liver, Spleen, Kidney, GB • Aorta and para-aortic glands • The urinary bladder • Rt & Lt lower quadrants. • If a swelling is palpable, illicit its features • Dipping method
  46. 46. Liver• Palpate both Rt & Lt lobes• Lt lobe is palpated in the middle line.• Rt lobe is palpated in the Rt MCL lateral to the rectus muscle. • Different methods for palpation • Both hands side by side with fingers pointing to the ribs • Rt hand parallel to the costal margin • Hooking method• Comment on: • Size: normal, enlarged, shrunken • Edge: sharp, rounded • Surface: smooth, nodular • Consistency: soft, firm, hard. • Tenderness.
  47. 47. Palpation of the Liver
  48. 48. Palpation of the Liver
  49. 49. Hooking Method
  50. 50. Spleen• Start from the Rt lower quadrant moving toward Lt costal margin while asking the pat to take deep breath.• Lt hand is placed over the lowermost rib cage posterolaterally.• If not palpable; repeat while the pat is in the Rt lateral position.• Try to feel the notch on the medial border.• In contrast to kidney swelling, you can’t get above the upper pole of the swelling.• Comment on the size, edge (sharp), tenderness, consistency.
  51. 51. Palpation of the Spleen
  52. 52. Kidney• Felt bimanually• Lt hand is placed in the renal angle• Rt hand is placed anteriorly in the lumbar region.• Ask the pat to take deep breath in, press Lt hand forwards and Rt hand backwards.• The kidney is felt as a rounded firm swelling between both hands (i.e. bimanually palpable) and can be pushed from one hand to the other.
  53. 53. Palpation of the Left Kidney
  54. 54. Palpation of the Right Kidney
  55. 55. Urinary Bladder • Normally not palpable. • If there is retention of urine: • It is felt as smooth, firm, regular, oval- shaped swelling in the suprapubic region. • Its upper border may reach the umbilicus. • Its lower border can‟t be felt (pelvi- abdominal mass) • In women, it has to be differentiated from gravid uterus, fibroid, ovarian cyst (usually eccentrically placed to Lt or Rt side)
  56. 56. The Aorta• May be palpated a little above the umbilicus.
  57. 57. Palpation of the Aorta
  58. 58. Dipping• When there is large amount of ascites, palpation of enlarged viscera may be difficult.• This method of palpation is performed by a quick pressure of the tips of the fingers over the region where the edge of the organ is expected.
  59. 59. Abdominal Mass• 1- make sure that it is not a normal structure: • pelvic colon particularly when loaded with stool, the caecum • The caecum: soft, rounded swelling • Lower pole of the Rt kidney• 2-Next consider whether it could be due to enlargement of intra-abd organs e.g liver, spleen, kidney, GB..
  60. 60. Abdominal MassComment on the following• Site: extra or intra-abd., abd or pelvi-abd• Size• Shape• Surface, edge, consistency• Mobility and attachment• Is it bimanually palpable? Renal• Is it pulsatile? Transmitted or expansile
  61. 61. III- Percussion• 1- To define the boundaries of abd organs e.g upper and lower border of the liver, spleen, urinary bladder.• 2- Detection of ascites” • Shifting dullness. • Knee-elbow position • Fluid thrill.
  62. 62. Percussion of Lower Border of the Liver
  63. 63. Percussion of the Upper Border of the Liver
  64. 64. Percussion of Urinary Bladder
  65. 65. Percussion of Ascites
  66. 66. Percussion of Ascites
  67. 67. ResonantAs the pat turns to the Rt, the fluid moves doand the Lt loin well be resonant on percussio
  68. 68. Fluid Thrill
  69. 69. IV- Auscultation• Minor role.• Done before palpation and percussion as touching the abdomen may alter the abd sounds.• Use the warm diaphragm, and listen for 15-20 sec.
  70. 70. • Examine for bowel sounds: • Are bowel sounds present or absent? • If present, are they frequent of sparse? Normal frequency is variable: every 5-10 sec • What is the quality of the sounds? Exaggerated in intest obst.• Succussion splash in pyloric obst• Vascular sounds: • Venous hum: in portal hypertension • Systolic murmur: suggest narrowing of an artery• Friction Rub: peri-hepatitis, peri-splenitis.
  71. 71. Succussion Splash
  72. 72. Auscultation for Renal Artery Stenosis
  73. 73. Auscultation for Hepatic Rub
  74. 74. Auscultation for Splenic Rub
  75. 75. Auscultation of Intestinal Sounds