EASY AND VERY UNDER STABLE

1. Mentor; Boniphace

3.  Dysphagia (and Odynophagia)
 Heartburn
 Reflux
 Indigestion (dyspepsia)
 Flatulence
 Vomiting
 Anorexia
 Constipation
 Diarrhoea

4.  Abdominal pain
 Abdominal distension
 Weight loss
 Haematemesis
 Melaena
 Rectal bleeding
 Jaundice

5.  Pain
 Haematuria
 Oliguria/Anuria
 Polyuria
 Frequency
 Nocturia
 Dysuria
 urgency of micturition, incontinence and enuresis
 Slow stream, hesitancy and terminal dribbling
 Urethral discharge.

6. ABDOMINAL EXAMINATION
 Inspection
 Palpation
 Percussion
 Auscultation

7. 1. Ask for consent before starting
2. The patient should be in supine position
3. Kneel just 1 meter away from the patient bed so
that to be the same level as the patient abdomen
4. Ask the patient the area with pain first
5. Expose only the part to be examined ( abdomen)
6. Examine the abdomen systematically ( sometime
you can start with auscultation first)
7. Always stand at the right side of the patient (
except if your left handed)

8. POSITIONING
 Abdomen can be divided in four quadrants.
 Patient should be lying on supine position.

11.  Shape
 Movements
 Scars
 Distension
 Localised: mass, organomegaly
 Generalized: 5 F’s
 Prominent veins (caput medusae)
 Striae
 Bruises
 Pigmentation
 Visible peristalsis

12.  Ensure that your hands are warm.
 Stand on the patient’s right side.
 Help to position the patient.
 Ask whether the patient feels any pain before you start.
 The wrist and the forearm should be in the same horizontal
plane where possible, even if this means bending down or
kneeling by the patient’s side.
 Manner of palpation varies according to the site of any pain,
but it is helpful to have a logical sequence to follow.
 Start palpating the left lower quadrant of the abdomen.
 Begin with superficial examination.
 Move in a systematic manner through the abdominal
quadrants.
 Repeat palpation deeply.

14.  Tenderness: discomfort and resistance to
palpation
 Involuntary guarding: reflex contraction of the
abdominal muscles
 Rebound tenderness: patient feels pain when
the hand is released
 Tenderness + rigidity: perforated viscus
 Palpable mass (enlarged organ, faeces,
tumour)
 Aortic pulsation

15.  Pain in RUQ
 Inflammation of gallbladder (cholecystitis)
 Courvoisier's law states that in a patient with painless
jaundice and an enlarged gallbladder(or RUQ mass),
the cause is unlikely to gallstones and therefore
presumes the cause to be an obstructing pancreatic or
biliary neoplasm until proven otherwise.

16.  a.k.a. rebound tenderness.
 Pain upon removal of pressure rather than
application of pressure to the abdomen.
 Peritonitis and/ or appendicitis.

17.  1/3 ASIS (anterior superior iliac spine) to
umbilicus.
 Location of AV(Atrioventicular) in retrocecal
position
 Deep tenderness (= acute appendicitis)

18.  Place the palm of your left hand against the
left side of the abdomen
 Flick a finger against the right side of the
abdomen.
 Ask the patient to put the edge of a hand on
the midline of the abdomen.
 If a ripple is felt upon flicking we call it a fluid
thrill = ascites

20. Left kidney
 Place left hand anteriorly in the left lumbar region.
 Place the right hand posteriorly in the left loin.
 Ask the patient to take a deep breath in, press the right
hand forwards and left hand backwards, upwards and
inwards.
Right kidney
 Place right hand horizontally in the right lumbar region
anteriorly
 Place the left hand posteriorly in the right loin.
 Ask the patient to take a deep breath in, push forward
with the left hand forwards and press right hand
inwards and upwards.

21. 1. Start palpating in the right iliac fossa
2. Ask the patient to take a deep breath in
3. Move your hand progressively further up the
abdomen
4. Try to feel the liver edge
5. Check for the liver span(liver size)

22.  Starting in the MCL at about the 3rd ICS, lightly
percuss and move down.
 Percuss inferiorly until dullness denotes the
liver’s upper border(usually at 5th ICS in MCL)
 Resume percussion from below the umbilicus
on the MCL in an area of tympany.
 Percuss superiorly until dullness indicates the
liver’s inferior border.
 Measure span in centimetres
 Normal liver span is 12-15 cm.

23.  Roll the patient towards you
 Palpate with your left hand while using your
left hand to press forward on the patient’s
lower ribs from behind
 Feel along the costal margin

24.  Dull sounds: solid or fluid-filled structures
 Resonant sounds: structures containing air or
gas
 Shifting dullness.

25.  Place the diaphragm of the stethoscope to the
right of the umbilicus.
 Bowel sounds (borborygmi) are caused by
peristaltic movements.
 Occur every 5-10 sec.
 Absence of bowel sounds: paralytic ileus or
peritonitis.
 Bruits over aorta and renal artery could be a
sign of an aneurysm and stenosis.

27. LEOPOLDS MANEUVER’S

28. Methods and principles of examining gravid
uterus
 The mother should be supine and comfortably
positioned with her abdomen bared
 These maneuvers may be difficult to perform
and interpret if:-
 –the patient is obese
 –if there is excessive amniotic fluid
 –if the placenta is anteriorly implanted

29.  Longitudinal inspection (symmetry and
distension)
 Vertical inspection –shape (longitudinal ovoid)
- movement with respiration
- linea nigra
- striae gravidarum
- umbilicus is flat
- distended veins
- therapeutic marks
- obvious fetal movement

32. FUNDAL GRIP-
AIM.what occupies the fundus and to measure fundal height
Broad soft and irregular mass suggestive of breech presentation
Smooth hard and globular mass suggestive of head
–Face the patient’s head
–Use both hands to palpate the fundus
–A mass is felt – is it head or buttocks?
 Consider:-
-Consistency
–the head is harder than the buttocks
-Shape
–the head is round
-Mobility
–the head moves independent of the trunk
–the breech moves with the trunk

34. LATERAL GRIP
 AIM:- 1.To locate the lie and back of the fetus in
relation to the right or left side of the mother
2. Check for Fetal Heart Rate
•Face the patient’s head
•Use the palms of both hands, one on either side of
the abdomen, so that one hand steadies (fix) the
uterus while the other palpates using a slight
circular motion from the top of the uterus to the
lower segment, feeling for fetal outline
•Palpate the other side, reversing the functions of the
hands

35. Consider:-
•The back will feel smooth and hard
•The knees and elbows will have numerous
angular nodulations
You can estimate the Fetal weight by using the
FH and abdominal girth

37. PAWLIK’S GRIP
 AIM:- To determine what is lying in the pelvic
inlet and to its mobility i.e the presenting part
•Important because the findings aid in
diagnosing
–presentation
–position
–engagement

38.  Face the patient’s head
•Gently grasp the lower portion of the abdomen
just above the symphysis pubis, using the
thumb and fingers of one hand
•If the presenting part is unengaged:-
–a moveable body will be noted which may be
gently balloted
-in transverse lie pawlik`s grip is empty

40. PELVIC GRIP
 AIM:- To locate the cephalic prominence to
assist in diagnosing descent into the pelvis i.e
engagement
•Face the patient’s feet
•The fingers of both hands are moved gently
down the sides of the uterus toward the pubis
•The cephalic prominence is located on the side
where the greatest resistance is felt

41.  If the prominence is located on the opposite
side from the fetal back, the head is said to be
well flexed
 If the prominence is located on the same side as
the back, the head is said to be extended (face
presentation)

44.  SUPERFICIAL PALPATION to elicit any area
of pain (tenderness)
 DEEP PALPATION to elicit any
organomegally
spleen (left iliac fossa- palpable or not)
liver ( right iliac fossa)
Kidney ( by balloting the right and left kidney)